erythromycin

Generic: Ery

250 mg, 333 mg, 500 mg — Tablet

CEPHALOSPORINS

Also known as: erythromycin oral Ilotycin Emcin, Erycette, EryGel, et. al. Emcin, EryDerm, EryMax, et. al erythromycin tab delayed release 250 mg, 333 mg, 500 mg erythromycin tab 250 mg, 500 mg erythromycin soln 2% Erythromycin 200 Mg/5 Ml Oral Suspension Erythromycin 400 Mg/5 Ml Oral Suspension Erythromycin 250 Mg Tablet Erythromycin 500 Mg Tablet Erythromycin Dr 250 Mg Capsule
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Silver with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Standard Gold
via Ery 		Tier 2 - Generic — — — None
Standard Silver
via Ery 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Ery 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Ery 		Tier 2 - Generic — — — None
Elite Bronze
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze
via Ery 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Ery 		Tier 2 - Generic — — — None
Complete Gold
via Ery 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Silver
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Gold
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold
via Ery-Tab 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Gold Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — — None
Elite Bronze Tier 4 - Non-Preferred — — — None
Everyday Bronze Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred — — — None
Complete Gold Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via Ery 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Ery 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Ery-Tab 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Ery 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026 Tier 3 - Mid-Range Cost — — — None
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