methylphenidate hcl

18 mg, 20 mg, 27 mg, 30 mg, 36 mg, 40 mg, 45 mg, 54 mg, 63 mg, 72 mg — Capsule

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS

Also known as: methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl cap er 24hr 15 mg (xr), 20 mg (xr), 30 mg (xr), 40 mg (xr), 50 mg (xr), 60 mg (xr) methylphenidate hcl soln 5 mg/5ml, 10 mg/5ml methylphenidate hcl tab er osmotic release (osm) 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl tab er 10 mg, 20 mg methylphenidate hcl tab 5 mg, 10 mg, 20 mg methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg (cd), 40 mg (cd), 50 mg (cd), 60 mg (cd) methylphenidate hcl cap er 24hr 10 mg (la), 20 mg (la), 30 mg (la), 40 mg (la) METHYLPHENIDATE ER QUILLICHEW ER RELEXXII methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg Methylphenidate HCl Oral Solution Methylphenidate HCl ER Oral Tablet Extended Release Methylphenidate HCl Oral Tablet Methylphenidate HCl Oral Tablet Chewable
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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: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Relexxii 		Tier 3 - Non-Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026
via Relexxii 		Tier 3 - Non-Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via Metadate Cd 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Metadate Cd 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026
via Metadate Cd 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via Metadate Cd 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026
via Metadate Cd 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 4400 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 3500 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP)
via METHYLPHENIDATE ER 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via METHYLPHENIDATE ER 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) 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 METHYLPHENIDATE ER 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via METHYLPHENIDATE 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
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 90 per 30 days QL
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Senior Care (HMO I-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via METHYLPHENIDATE ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via METHYLPHENIDATE ER 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Aetna Medicare Signature (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 90 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan II (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via METHYLPHENIDATE ER 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Relexxii 		Non-Preferred — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 17 hours, 57 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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