omeprazole

10 mg, 20 mg, 40 mg — Delayed Release Capsule

PROTON PUMP INHIBITORS

Also known as: Omeprazole Dr 10 Mg Capsule Omeprazole Dr 20 Mg Capsule Omeprazole Dr 40 Mg Capsule Omeprazole Oral Capsule Delayed Release Omeprazole Magnesium Oral Capsule Delayed Release
GoodRx Compare Prices

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, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze Tier 2 - Generic — — ✓ QL
Standard Silver Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO) Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 1 - Preferred Generic — — — None
Erickson Advantage Signature (HMO-POS) Tier 1 - Preferred Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 1 - Preferred Generic — — — None
Erickson Advantage Freedom (HMO-POS) Tier 1 - Preferred Generic — — — None
Erickson Advantage Liberty (HMO-POS) Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Prime (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO) Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) 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
Humana Gold Plus H1036-335 (HMO-POS) Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 1 - Preferred Generic — — — None
HumanaChoice H5216-211 (PPO) Tier 1 - Preferred Generic — — — None
Humana Full Access H5525-034 (PPO) Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 1 - Preferred Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-049 (PPO) Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-050 (PPO) Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-070 (PPO) Tier 1 - Preferred Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-083 (PPO) Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 1 - Preferred Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 1 - Preferred Generic — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 1 - Preferred Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) 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) Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Blue Medicare Choice (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Blue Medicare Essential (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO) Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO) Tier 1 - Preferred Generic — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Source: CMS QHP JSON  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Diabetes | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
AIAN Cost Share Tier 1 - Preferred Generic — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Classic | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Secure | with Atrium Health Tier 1 - Preferred Generic — — ✓ QL
Silver Simple Diabetes Tier 1 - Preferred Generic — — ✓ QL
Gold Elite Saver Plus Tier 1 - Preferred Generic — — ✓ QL
Silver Simple PCP Saver Tier 1 - Preferred Generic — — ✓ QL
Bronze Classic 4700 Tier 1 - Preferred Generic — — ✓ QL
Secure Tier 1 - Preferred Generic — — ✓ QL
Silver Classic Tier 1 - Preferred Generic — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 1 - Preferred Generic — — ✓ QL
Bronze Classic Standard Tier 2 - Generic — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Classic Standard Tier 2 - Generic — — ✓ QL
Silver Classic Standard Tier 2 - Generic — — ✓ QL
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 22 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 1 - Preferred Generic — — — None
Something not right?