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, hydrOXYzine Pamoate Oral Capsule
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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: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Signature Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Signature Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Signature Expanded Bronze Tier 2 - Generic — — — None
Signature Silver Tier 2 - Generic — — — None
Signature Gold Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 2 - Generic — — — None
Streamlined Silver Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 3 hours, 24 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: Oct 1, 2026  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 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 Value 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Vistaril 		Tier 1 - Lowest Cost Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-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
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
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
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) 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
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring TotalCare Plus (HMO D-SNP) 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
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
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — — None
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 - Diabetes and Heart (HMO C-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
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 012 NC (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
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred ✓ — — PA
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple Open (PPO) 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 Giveback Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred ✓ — — PA
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
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) 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
Aetna Medicare Signature (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
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Erickson Advantage Liberty (HMO-POS) 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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
Source: CMS QHP JSON  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Elite Saver Plus Tier 1 - Preferred Generic — — — None
Silver Simple Diabetes Tier 1 - Preferred Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 1 - Preferred Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 1 - Preferred Generic — — — None
Secure | with Atrium Health Tier 1 - Preferred Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 1 - Preferred Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Classic | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple PCP Saver | with Atrium Health Tier 1 - Preferred Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 1 - Preferred Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 1 - Preferred Generic — — — None
AIAN Cost Share Tier 1 - Preferred Generic — — — None
AIAN Cost Share | with Atrium Health Tier 1 - Preferred Generic — — — None
Silver Simple PCP Saver Tier 1 - Preferred Generic — — — None
Bronze Classic 4700 Tier 1 - Preferred Generic — — — None
Secure Tier 1 - Preferred Generic — — — None
Silver Classic Tier 1 - Preferred Generic — — — None
Bronze Elite + PCP Saver Plus Tier 1 - Preferred Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 3 hours, 24 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
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