Oxycodone

5 Ml — Tablet

Also known as: OxyContin OxyIR Oxycodone 100 Mg/5 Ml Oral Concentrate Oxycodone 5 Mg/5 Ml Oral Solution

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

29 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Expanded Bronze via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Focused Silver with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL

Blue Cross Blue Shield Federal

1 plan

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via OxyContin	Tier 3 - Non-Preferred Brand	✓	—	—	PA

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Roxicodone	Tier 1 - Lowest Cost Generic	—	—	✓	QL
BCBSNC Blue Care 2026 via Roxicodone	Tier 1 - Lowest Cost Generic	—	—	✓	QL
BCBSNC Blue Value 2026 via Roxicodone	Tier 1 - Lowest Cost Generic	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Roxicodone	Tier 1 - Lowest Cost Generic	—	—	✓	QL
BCBSNC Blue Advantage 2026 via Roxicodone	Tier 1 - Lowest Cost Generic	—	—	✓	QL
BCBSNC Blue Advantage 2026 via Xtampza Er	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Local 2026 via Xtampza Er	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Care 2026 via Xtampza Er	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Value 2026 via Xtampza Er	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Xtampza Er	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL

Cigna

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026	Tier 1 - Generic	✓	—	—	PA

Medicare Part D

46 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Liberty Medicare Dual Plan (HMO D-SNP) via OxyContin	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via OxyContin	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
NHC Advantage (HMO I-SNP) via OxyContin	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
PruittHealth Premier (HMO I-SNP) via OxyContin	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
Senior Care (HMO I-SNP) via OxyContin	Tier 2 - Generic	✓	—	✓ 60 per 30 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP) via OxyContin	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Giveback (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Extra (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Care (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Prime (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Value Plus (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via OxyContin	Tier 4 - Non-Preferred	✓	—	✓ 60 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 30 per 30 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via OxyContin	Tier 4 - Non-Preferred	✓	—	✓ 60 per 30 days	PA \| QL
Troy Medicare (HMO) via OxyContin	Tier 4 - Non-Preferred	✓	—	✓ 60 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CORE 001 NC (HMO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Abuse-Deterrent	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via OxyContin	Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Roxicodone	Non-Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026	Non-Preferred	✓	—	—	PA

NC State Health Plan

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Roxicodone	Tier 3 - Non-Preferred Brand	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026 via Roxicodone	Tier 3 - Non-Preferred Brand	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026 via Roxicodone	Tier 3 - Non-Preferred Brand	✓	—	✓	PA \| QL

UnitedHealthcare

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 18 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UnitedHealthcare NC Individual & Family 2026 via Xtampza Er	Tier 4 - Higher Cost	✓	—	✓	PA \| QL