HYDROCODONE-ACETAMIN

300 MG

Opioid Agonist

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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: 9 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect myDiabetesCare Bronze Tier 2 - Generic ✓ — — PA
Connect myDiabetesCare Silver Tier 2 - Generic ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic ✓ — — PA
Connect Gold RD CMS Standard Tier 2 - Generic ✓ — — PA
Connect Silver CMS Standard Tier 2 - Generic ✓ — — PA
Connect Silver RD CMS Standard Tier 2 - Generic ✓ — — PA
Connect Bronze RD CMS Standard Tier 2 - Generic ✓ — — PA
Connect Bronze CMS Standard Tier 2 - Generic ✓ — — PA
Connect Gold CMS Standard Tier 2 - Generic ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 9 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — ✓ 5550 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 2700 per 30 days QL
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