Norgestimate-Ethinyl Estradiol

0.18 mg (7)/0.215 mg (7)/0.25 mg (7) with 0.035 mg (28), 0.25 mg-0.035 mg — Tablet

Also known as: Norgestimate-Ethinyl Estradiol 0.25-0.035 Mg Tablet TRI-LINYAH TRI-VYLIBRA TRI-NYMYO MILI MONO-LINYAH TRI-SPRINTEC VYLIBRA TRI-ESTARYLLA TRI-MILI SPRINTEC ESTARYLLA

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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.

AmeriHealth Caritas NC

80 plans

Source: CMS QHP JSON · Checked: 18 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Bronze Essential + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via mono-linyah	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via tri-vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via vylibra	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via tri-mili	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Estarylla	Tier 2 - Generic	—	—	—	None

Blue Cross Blue Shield Federal

24 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026 via tri-vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via Estarylla	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via Mili	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via mono-linyah	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via TRI-LINYAH	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via tri-mili	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via Tri-Sprintec	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via tri-vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Standard Option 2026 via vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via Estarylla	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via Mili	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via mono-linyah	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via TRI-LINYAH	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via tri-mili	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via Tri-Sprintec	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via tri-vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Basic Option 2026 via vylibra	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via Estarylla	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via Tri-Sprintec	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via Mili	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via mono-linyah	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via TRI-LINYAH	Tier 1 - Generic	—	—	— NCTM	None
BCBS Federal Focus 2026 via tri-mili	Tier 1 - Generic	—	—	— NCTM	None

Cigna

180 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 18 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Bronze RD 6000 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via tri-vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Tri-Sprintec	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via TRI-LINYAH	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via mono-linyah	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Tri-Estarylla	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Mili	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via tri-mili	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via vylibra	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via vylibra	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via tri-mili	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via tri-vylibra	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Mili	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Estarylla	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via mono-linyah	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via TRI-LINYAH	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Tri-Sprintec	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Tri-Estarylla	Tier 2 - Generic	—	—	—	None

NC State Health Plan

24 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via mono-linyah	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Estarylla	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Estarylla	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Estarylla	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via tri-vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via tri-vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via tri-vylibra	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Tri-Sprintec	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Tri-Sprintec	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Tri-Sprintec	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via tri-mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via tri-mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via tri-mili	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via TRI-LINYAH	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via TRI-LINYAH	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via TRI-LINYAH	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via mono-linyah	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via mono-linyah	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 18 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None