Hydroxychloroquine Sulfat

Generic: hydroxychloroquine sulfate

ANTIMALARIALS

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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: 2 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Silver
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Gold
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Complete Gold
via hydroxychloroquine sulfate 		Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 2 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Premier + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via hydroxychloroquine sulfate 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via hydroxychloroquine sulfate 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via hydroxychloroquine sulfate 		Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 1 hour, 59 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Community Plan (HMO I-SNP)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring Preferred (HMO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 1 hour, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — — None
Source: CMS QHP JSON  ·  Checked: 1 hour, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Diabetes | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AIAN Cost Share
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Classic
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Secure
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Classic 4700
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Classic Standard
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Classic Standard
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Gold Classic Standard
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via hydroxychloroquine sulfate 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 1 hour, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard (No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Standard (No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Standard (No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via hydroxychloroquine sulfate 		Tier 1 - Preferred Generic — — ✓ QL
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