Levothyroxine

100 Mcg — Tablet

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.

Ambetter (Centene)

116 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 18 hours 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
Complete Gold + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze + 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 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
Complete Gold with Atrium Health + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold + 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
Standard Silver with Atrium Health + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold 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
Everyday Bronze via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold 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
Standard Silver with Atrium Health via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health 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
Complete Gold + Vision + Adult Dental via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze + 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 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
Focused Silver with Atrium Health + 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
Standard Expanded Bronze + 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 Gold + 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 Silver with Atrium Health + Vision + Adult Dental via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold 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
Everyday Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold 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
Standard Silver with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health 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
Complete Gold + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze + 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 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
Focused Silver with Atrium Health + 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
Standard Expanded Bronze + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver + 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 with Atrium Health + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental 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 Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver with Atrium Health via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health 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
Complete Gold + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze + 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 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
Complete Gold with Atrium Health + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold + 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 Silver with Atrium Health + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Silver with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Standard Gold with Atrium Health via Unithroid	Tier 1 - Preferred Generic	—	—	—	None

AmeriHealth Caritas NC

30 plans

Source: CMS QHP JSON · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Signature + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Levoxyl	Brand-Preferred	—	—	—	None

Blue Cross Blue Shield Federal

7 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours 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

Cigna

80 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Bronze RD 6000 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Levoxyl	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 Silver CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Levo-T	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Bronze via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Levoxyl	Tier 2 - Generic	—	—	—	None

Medicare Part D

554 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Humana Gold Plus H1036-233 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Freedom (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS)	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)	Tier 1 - Preferred Generic	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP)	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 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 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 Signature (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	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)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	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)	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring True Choice (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring True Choice (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred (HMO)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Plus (HMO)	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)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	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)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	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)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	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
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)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	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)	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)	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)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP)	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)	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)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Simple (HMO-POS)	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)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Giveback Open (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Blue Medicare PPO Enhanced (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Blue Medicare Essential Plus (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Blue Medicare Enhanced (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Blue Medicare Choice (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Blue Medicare Essential (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Experience Health Medicare Advantage (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	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 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 smartHMO (HMO) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO)	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
HealthTeam Advantage Plan I (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	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)	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Troy Medicare (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	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)	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)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Assist Open (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	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)	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)	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
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)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	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)	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
Senior Care (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Senior Care (HMO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Levoxyl	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Unithroid	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
HealthTeam Advantage Plan II (PPO) via Levoxyl	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Levoxyl	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Unithroid	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Levoxyl	Tier 2 - Generic	—	—	—	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 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-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-0009 (HMO-POS) 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-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
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
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
HealthSpring True Choice (PPO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Unithroid	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 levothyroxine sodium	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Unithroid	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
Blue Medicare PPO Enhanced (PPO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Levoxyl	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS 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
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
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
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
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
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-0001 (PPO) 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-0011 (HMO-POS) via Unithroid	Tier 3 - Preferred Brand	—	—	—	None
Troy Medicare (HMO) via Levoxyl	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 Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Unithroid	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Levoxyl	Tier 4 - Non-Preferred	—	—	—	None

NC State Health Plan

15 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Unithroid	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 - 80/20 Plus PPO 2026 via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Levoxyl	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 - 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 - HDHP 2026 via levothyroxine sodium	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 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 levothyroxine sodium	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via levothyroxine sodium	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Thyquidity	Not Covered	—	—	—	None

Oscar Health

84 plans

Source: CMS QHP JSON · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AIAN Cost Share \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Classic via Levoxyl	Tier 2 - Generic	—	—	—	None
Secure via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via Levoxyl	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via Levoxyl	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Classic via Unithroid	Tier 2 - Generic	—	—	—	None
Secure via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via Unithroid	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via Unithroid	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via Unithroid	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Unithroid	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Secure via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via Levoxyl	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via Levoxyl	Tier 2 - Generic	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via levothyroxine sodium	Tier 1 - Basic Core Formulary	✓	—	—	PA

UnitedHealthcare

65 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 18 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Levoxyl	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Unithroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Levo-T	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Standard (No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Standard (No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Standard+ Dental + Vision (No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Standard (No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Thyquidity	Tier 4 - Non-Preferred	✓	—	—	PA