GLYBURID-METFORMIN

250 MG

Sulfonylurea

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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: PDF  ·  Formulary date: Jul 24, 2026  ·  Checked: 10 hours ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 10 hours ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
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
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan II (PPO) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage 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 Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — ✓ 240 per 30 days PA | QL
Troy Medicare (HMO) Tier 2 - Generic ✓ — ✓ 240 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus — — — None
Experience Health Medicare Advantage (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Blue Medicare Essential (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Blue Medicare Choice (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health Platinum (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health smartHMO (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health AVA (PPO) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 6 - Specialty Plus — — ✓ 240 per 30 days QL
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