metformin hcl

1,000 mg, 500 mg, 625 mg, 750 mg, 850 mg — Tablet

ANTIDIABETICS

Also known as: metformin hcl oral solution metformin hcl oral tablet 1000 mg metformin hcl soln 500mg/5ml metformin hcl tabs 500mg, 1000mg; tb24 500mg, 750mg metformin hcl tabs 625mg metformin hcl tabs 850mg metformin hcl tab er 24hr 500 mg, 750 mg metformin hcl tab 500 mg, 850 mg, 1000 mg metformin hcl tabs 500mg, 850mg, 1000mg; tb24 500mg, 750mg GLUMETZA METFORMIN ER GASTRIC METFORMIN ER OSMOTIC METFORMIN HCL ER metformin hcl tabs 500mg, 1000mg; tb24 metFORMIN HCl ER Oral Tablet Extended Release metFORMIN HCl Oral Tablet
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 19 hours, 32 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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026 Tier 1 - Lowest Cost Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 2200 Indiv Med Deductible 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 Bronze 5500 Indiv Med Deductible 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 myDiabetesCare Silver Tier 1 - Preferred Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via metformin hcl er 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via metformin hcl er 		Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Complete Care NC-27 (HMO-POS C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Value Plus (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Prime (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Care (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Prime (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring True Choice (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring Preferred (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
NHC Advantage (HMO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via metformin hcl er 		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 metformin hcl er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via metformin hcl er 		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 (HMO C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan II (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via metformin hcl er 		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
Humana Gold Plus H1036-335 (HMO-POS) Tier 1 - Preferred Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 75 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via metformin hcl er 		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
Humana Gold Plus H1036-137 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice H5216-211 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Full Access H5525-034 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-049 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-050 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-070 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-083 (PPO)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via metformin hcl er 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
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
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
Senior Care (HMO I-SNP)
via metformin hcl er 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Giveback Open (PPO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 6 - Specialty Plus — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Simple (HMO-POS)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus — — — None
Alignment Health AVA (PPO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health smartHMO (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health Platinum (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Alignment Health AVA (PPO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health Platinum Select (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health smartHMO (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Blue Medicare Essential (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Blue Medicare Choice (HMO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Experience Health Medicare Advantage (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Blue Medicare Essential (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Blue Medicare Choice (HMO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Assist Open (PPO) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via metformin hcl er 		Tier 6 - Specialty Plus — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 6 - Specialty Plus — — ✓ 75 per 30 days QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - HDHP 2026
via metformin hcl tb24 		Not Covered — — — (generic for GLUMTEZA) None
NC State Health Plan - 80/20 Plus PPO 2026
via metformin hcl tb24 		Not Covered — — — (generic for GLUMTEZA) None
NC State Health Plan - 70/30 Standard PPO 2026
via metformin hcl tb24 		Not Covered — — — (generic for GLUMTEZA) None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 19 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
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