HYDROCODONE ER

100 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, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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 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 3000 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 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
Connect Gold RD CMS Standard Tier 2 - Generic ✓ — — PA
Connect Silver CMS Standard Tier 2 - Generic ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 9 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
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