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, 6 minutes ago

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

AmeriHealth Caritas NC

20 plans

Source: CMS QHP JSON · Checked: 18 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via OxyContin	Tier 4 - Non-Preferred	✓	—	—	PA

Blue Cross Blue Shield Federal

1 plan

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours, 6 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: Jul 1, 2026 · Checked: 18 hours, 6 minutes ago

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

Cigna

20 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 18 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 5000 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect myDiabetesCare Silver via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver RD 2200 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Gold 1500 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect myDiabetesCare Bronze via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze 5500 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze RD 6000 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver 3500 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze RD 5000 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver RD 3500 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze 7000 HSA Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver 4400 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver 3000 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze 6500 Indiv Med Deductible via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Silver RD CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Gold CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze RD CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Gold RD CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA
Connect Bronze CMS Standard via Xtampza Er	Tier 3 - Preferred Brand	✓	—	—	PA

Medicare Part D

85 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 18 hours, 6 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
PruittHealth Premier (HMO I-SNP) via OxyContin	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
NHC Advantage (HMO I-SNP) via OxyContin	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Xtampza Er	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Xtampza Er	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Xtampza Er	Tier 1 - Preferred Generic	—	—	—	None
Senior Care (HMO I-SNP) via OxyContin	Tier 2 - Generic	✓	—	✓ 60 per 30 days	PA \| QL
HealthTeam Advantage Vitality Plan (PPO) via Xtampza Er	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Xtampza Er	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via OxyContin	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Plan I (PPO) via Xtampza Er	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Xtampza Er	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	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
Aetna Medicare Value Plus (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 Signature Care (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 Enhanced (HMO) 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 (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 Extra (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 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
Erickson Advantage Champion (HMO-POS C-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	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
Erickson Advantage Freedom (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
Troy Medicare (HMO) via OxyContin	Tier 4 - Non-Preferred	✓	—	✓ 60 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
AmeriHealth Caritas VIP Care (HMO D-SNP) via OxyContin	Tier 4 - Non-Preferred	✓	—	✓ 60 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
Erickson Advantage Signature (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Xtampza Er	Tier 4 - Non-Preferred	—	—	✓ 90 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) 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 CHOICE GIVEBACK 006 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
DEVOTED DUAL FULL 013 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 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

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours, 6 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	Non-Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Roxicodone	Non-Preferred	✓	—	—	PA

NC State Health Plan

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 18 hours, 6 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

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 18 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
AIAN Cost Share via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
AIAN Cost Share \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Secure via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic 4700 via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple PCP Saver via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Elite Saver Plus via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Secure \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Elite Saver Plus \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Elite Saver Plus \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
AIAN Cost Share \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
AIAN Cost Share via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Secure via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Elite Saver Plus via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Secure \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via OxyContin	Tier 3 - Preferred Brand	—	—	✓	QL