Nicorette

Generic: nicotine

2 MG

Cholinergic Nicotinic Agonist

Also known as: nicotine
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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: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Focused Silver with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold
via Thrive 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Thrive 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via Thrive 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via Thrive 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Silver
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Gold
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Silver
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Gold
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via Thrive 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Thrive 		Tier 0 - $0 Preventive — — — None
Complete Gold
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Nicotrol 		Tier 0 - $0 Preventive — — — None
Complete Gold
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Clear Silver with $0 Insulin Options
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Clear Silver with $0 Insulin Options
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Focused Silver with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold with Atrium Health
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Habitrol 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold
via nicotine 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via nicotine 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via nicotine 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via nicotine 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Silver
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Gold
via nicotine 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via nicotine 		Tier 0 - $0 Preventive — — — None
Complete Gold Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 0 - $0 Preventive — — — None
Everyday Bronze Tier 0 - $0 Preventive — — — None
Elite Bronze Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze Tier 0 - $0 Preventive — — — None
Standard Silver Tier 0 - $0 Preventive — — — None
Standard Gold Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Nicorelief 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via nicotine 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Nicotrol 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Nicotrol 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Nicotrol 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Nicotrol 		Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Nicotrol 		Brand-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via nicotine pt24 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via nicotine pt24 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - HDHP 2026
via nicotine pt24 		Tier 0 - $0 Copay (ACA Preventive) — — — None
Source: CMS QHP JSON  ·  Checked: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Diabetes | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
AIAN Cost Share
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
AIAN Cost Share | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic Standard
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Classic Standard
via nicotine 		Tier 0 - $0 Preventive — — — None
Gold Classic Standard
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Classic Standard | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Classic Standard | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Gold Classic Standard | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Elite + PCP Saver Plus
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Classic
via nicotine 		Tier 0 - $0 Preventive — — — None
Secure
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Classic 4700
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple PCP Saver
via nicotine 		Tier 0 - $0 Preventive — — — None
Gold Elite Saver Plus
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Diabetes
via nicotine 		Tier 0 - $0 Preventive — — — None
Secure | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Classic 4700 | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Classic | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Diabetes | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple PCP Saver | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Gold Elite Saver Plus | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Bronze Simple Diabetes | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
AIAN Cost Share
via nicotine 		Tier 0 - $0 Preventive — — — None
AIAN Cost Share | with Atrium Health
via nicotine 		Tier 0 - $0 Preventive — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic Standard
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic Standard
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Gold Classic Standard
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic Standard | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic Standard | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Gold Classic Standard | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Elite + PCP Saver Plus
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Secure
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic 4700
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple PCP Saver
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Gold Elite Saver Plus
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Diabetes
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Secure | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Nicotrol 		Tier 0 - $0 Preventive — — ✓ QL
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via nicotine 		Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 22 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Silver Standard (No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 0 - $0 Preventive — — — None
UHC Silver Standard (No Referrals) Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals) Tier 0 - $0 Preventive — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 0 - $0 Preventive — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Gold Standard (No Referrals) Tier 0 - $0 Preventive — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 0 - $0 Preventive — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Gold Standard (No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Silver Standard (No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Gold Standard (No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Nicotrol 		Tier 0 - $0 Preventive ✓ — — PA
UHC Gold Standard (No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Standard (No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Nicoderm C-Q 		Tier 0 - $0 Preventive — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Gold Standard (No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Silver Standard (No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via nicotine 		Tier 0 - $0 Preventive — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Thrive 		Tier 0 - $0 Preventive — — — None
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