indomethacin er

75 MG

Nonsteroidal Anti-inflammatory Drug

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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: Jan 1, 2026  ·  Checked: 21 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 21 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage 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 Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-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
Humana Gold Plus H6622-057 (HMO-POS) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO) Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO) Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO) Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO) Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
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