levothyroxine sodium

Generic: Euthyrox

100 mcg, 100 mcg/5 mL (20 mcg/mL), 112 mcg, 125 mcg, 137 mcg, 150 mcg, 150 mcg/5 mL (30 mcg/mL), 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg — Tablet

ANTIDIABETICS

Also known as: levothyroxine sodium oral tablet levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg levothyroxine sodium caps 13mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg levothyroxine sodium caps 13mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg; tabs 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg THYQUIDITY LEVO-T SYNTHROID EUTHYROX ERMEZA levothyroxine sodium caps 13mcg, 25mcg,
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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: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options Tier 1 - Preferred Generic — — — None
Elite Bronze Tier 1 - Preferred Generic — — — None
Complete Gold Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 1 - Preferred Generic — — — None
Everyday Bronze Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver Tier 1 - Preferred Generic — — — None
Standard Gold Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Tirosint 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Tirosint 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Local 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026
via Euthyrox 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Synthroid 		Tier 3 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
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
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
HealthTeam Advantage Plan I (PPO) 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
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 Gold Plus H1036-233 (HMO-POS) 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 - Diabetes and Heart (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) 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
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
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
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 1 - Preferred Generic — — — None
HealthSpring True Choice (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
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
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 PLUS 006 NC (HMO D-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) 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 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
NHC Advantage (HMO I-SNP)
via Synthroid 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Synthroid 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Synthroid 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Synthroid 		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
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) 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
Wellcare Simple Open (PPO) Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO) 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
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
Erickson Advantage Signature (HMO-POS) 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
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) 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
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) 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 Reserve (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Synthroid 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Synthroid 		Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Synthroid 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jan 5, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Synthroid 		Tier 3 - Mid-Range Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Tirosint-Sol 		Unknown ✓ — — PA
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