Orilissa

Generic: elagolix

150MG, 200MG — Tablet

OXYTOCICS

Also known as: ORILISSA TABS 150MG, 200MG elagolix Orilissa Oral Tablet
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand ✓ — — PA
Standard Expanded Bronze Tier 3 - Preferred Brand ✓ — — PA
Elite Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Standard Silver with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Standard Gold with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Standard Silver Tier 3 - Preferred Brand ✓ — — PA
Standard Gold Tier 3 - Preferred Brand ✓ — — PA
Focused Silver with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Complete Gold with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — — PA
Complete Gold Tier 3 - Preferred Brand ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand ✓ — — PA
Everyday Bronze Tier 3 - Preferred Brand ✓ — — PA
Elite Bronze Tier 3 - Preferred Brand ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand ✓ — — PA
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Oriahnn 28 Day Kit 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Oriahnn 28 Day Kit 		Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO)
via Oriahnn 28 Day Kit 		Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO) Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 18 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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