Levothyroxine

100 Mcg — Tablet

l-Thyroxine

Also known as: Levothyroxine 25 Mcg Tablet Levothyroxine 50 Mcg Tablet Levothyroxine 75 Mcg Tablet Levothyroxine 88 Mcg Tablet Levothyroxine 100 Mcg Tablet Levothyroxine 112 Mcg Tablet Levothyroxine 125 Mcg Tablet Levothyroxine 137 Mcg Tablet Levothyroxine 150 Mcg Tablet Levothyroxine 175 Mcg Tablet Levothyroxine 200 Mcg Tablet Levothyroxine 300 Mcg Tablet
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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: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Unithroid 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Unithroid 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Unithroid 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Unithroid 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Unithroid 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Levo-T 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Levo-T 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Levo-T 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Levo-T 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Levo-T 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Unithroid 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Unithroid 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Unithroid 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Unithroid 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Thyquidity 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026
via Levoxyl 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Unithroid 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Levo-T 		Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED GIVEBACK 012 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Choice (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Essential (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Experience Health Medicare Advantage (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Signature (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Value Plus (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Prime (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Care (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Value Plus (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Prime (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Care (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Value Plus (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Prime (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Care (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Extra (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring True Choice (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Select (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Savings (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Plus (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan II (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Assist Open (PPO)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Assist Open (PPO)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Assist Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Unithroid 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5216-211 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Full Access H5525-034 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-049 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-050 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-070 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-083 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via Levoxyl 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO)
via Unithroid 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Levoxyl 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO)
via Levoxyl 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via Levoxyl 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Unithroid 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Levoxyl 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Unithroid 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via Unithroid 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via levothyroxine sodium 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via levothyroxine sodium 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via Levoxyl 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Unithroid 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Unithroid 		Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO)
via Unithroid 		Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Levoxyl 		Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO)
via Levoxyl 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Unithroid 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Levoxyl 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Levoxyl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Levo-T 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Levo-T 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Levo-T 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Unithroid 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Levoxyl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Levoxyl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Unithroid 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Unithroid 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Thyquidity 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Thyquidity 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Thyquidity 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jan 5, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via levothyroxine sodium 		Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 11 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Levoxyl 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via levothyroxine sodium 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Unithroid 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Levo-T 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Thyquidity 		Unknown ✓ — — PA
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