Hydroxychloroquine

200 Mg — Tablet

Also known as: Hydroxychloroquine 200 Mg Tablet

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 22 hours, 5 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Plaquenil	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Plaquenil	Tier 3 - Non-Preferred Brand	—	—	—	None

5 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 22 hours, 5 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Plaquenil	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Plaquenil	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Plaquenil	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Plaquenil	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Plaquenil	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 22 hours, 5 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026	Tier 1 - Generic	—	—	—	None

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 22 hours, 5 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Plaquenil	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Plaquenil	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Plaquenil	Tier 3 - Non-Preferred Brand	—	—	—	None