Sitagliptin-metformin Er

Generic: sitagliptin/metformin HCl

100-1000MG, 50-1000 MG, 50MG-500MG — Extended Release Tablet

Coverage by Insurer

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

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 8 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Zituvimet	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Zituvimet XR	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via sitagliptin-metformin	Non-Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 8 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Zituvimet	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Zituvimet	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Zituvimet	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Zituvimet XR	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Zituvimet XR	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Zituvimet XR	Tier 2 - Non-Preferred Generic	—	—	—	None

Oscar Health

54 plans

Source: CMS QHP JSON · Formulary date: Oct 13, 2026 · Checked: 8 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Gold Classic Standard via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Secure \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010074 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010075 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010076 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010077 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010078 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010079 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010080 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010081 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010082 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010083 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010084 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010085 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Core Plan via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Core Plan \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010108 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010110 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010111 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010112 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010113 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010114 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010115 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010116 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010117 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010109 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Secure via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard via Zituvimet	Tier 3 - Preferred Brand	—	—	✓	QL

TRICARE

4 plans

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 8 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via Zituvimet	Tier 3 - Non-Formulary	✓	—	—	PA PA: TPA - SELECT DRUGS REQUIRES PRIOR AUTHORIZATION (NEW TO MARKET DRUGS)
TRICARE Uniform Formulary 2026 via sitagliptin-metformin	Tier 3 - Non-Formulary	✓	—	—	PA PA: TPA - SELECT DRUGS REQUIRES PRIOR AUTHORIZATION (NEW TO MARKET DRUGS)
TRICARE Uniform Formulary 2026 via Zituvimet XR	Tier 3 - Non-Formulary	✓	—	—	PA PA: TPA - SELECT DRUGS REQUIRES PRIOR AUTHORIZATION (NEW TO MARKET DRUGS)
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA PA: TPA - SELECT DRUGS REQUIRES PRIOR AUTHORIZATION (NEW TO MARKET DRUGS)