OxyContin

Generic: Oxycodone

10MG, 15MG, 20MG, 30MG — Tablet

Opioid Analgesics — Long Acting Opioids

Also known as: Abuse-Deterrent OXYCONTIN T12A 10MG, 15MG, 20MG, 30MG OXYCONTIN T12A 40MG, 60MG, 80MG OxyCONTIN Oral Tablet ER
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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: 15 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Silver
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
Complete Gold + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
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
Everyday Bronze 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
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
Signature Expanded Bronze + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
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 $0 Rx 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
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Roxicodone 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Advantage 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 Local 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 Xtampza Er 		Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Advantage 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
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
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 15 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 5000 Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze 5500 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 Bronze 7000 HSA Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Gold RD CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 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 RD CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze RD 6000 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 Gold 1500 Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect myDiabetesCare Silver
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect myDiabetesCare Bronze
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Gold CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze CMS Standard
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 3000 Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 3600 Indiv Med Deductible
via Xtampza Er 		Tier 3 - Preferred Brand ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 60 per 30 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 60 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Xtampza Er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Xtampza Er 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Xtampza Er 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic ✓ — ✓ 60 per 30 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Xtampza Er 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Xtampza Er 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Xtampza Er 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Xtampza Er 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 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 Chronic Care (HMO C-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 Chronic Care Value (HMO C-SNP)
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
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
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-0021 (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
AARP Medicare Advantage from UHC NC-0007 (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-0008 (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-0011 (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 Giveback from UHC NC-13 (HMO-POS)
via Xtampza Er 		Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (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
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-S3 (HMO-POS D-SNP)
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 Complete Care NC-25 (HMO-POS C-SNP)
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
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-28 (HMO-POS C-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
Erickson Advantage Guardian (HMO-POS I-SNP)
via Xtampza Er 		Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Xtampza Er 		Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
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
Troy Medicare (HMO) Tier 4 - Non-Preferred ✓ — ✓ 60 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 60 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 60 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 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 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 GIVEBACK 009 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 006 NC (PPO)
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 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 GIVEBACK 012 NC (HMO)
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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred ✓ — — PA
NC Medicaid Preferred Drug List 2026
via Oxycodone 		Non-Preferred ✓ — — PA
NC Medicaid Preferred Drug List 2026
via Roxicodone 		Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via Roxicodone 		Tier 3 - Non-Preferred Brand ✓ — ✓ PA | QL
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
Source: CMS QHP JSON  ·  Checked: 15 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple PCP Saver
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
Bronze Simple Diabetes | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic | 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
Bronze Classic 4700 | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Secure | 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 Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold 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
Bronze Classic Standard | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic 4700
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Secure
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share
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
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Secure | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 Tier 3 - Preferred Brand — — ✓ QL
Secure Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
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