hydroxyzine pamoate

25mg, 50mg, 100mg — Capsule

GENITOURINARY AGENTS - MISC.

Also known as: hydroxyzine pamoate oral hydroxyzine pamoate caps 25mg, 50mg, 100mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg Hydroxyzine Pamoate 25 Mg Capsule Hydroxyzine Pamoate 50 Mg Capsule Hydroxyzine Pamoate 100 Mg Capsule hydroxyzine pamoate caps 25mg, 50mg,
GoodRx Compare Prices

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: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand ✓ — — PA
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand ✓ — — PA
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand ✓ — — PA
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health AVA (PPO) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Vistaril 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026 Tier 1 - Preferred Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 2 - Lower Cost — — — None
Something not right?