Synthroid

Generic: levothyroxine sodium

25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG — Tablet

ANTIDIABETICS

Also known as: levothyroxine sodium Synthroid 25 Mcg Tablet Synthroid 50 Mcg Tablet Synthroid 75 Mcg Tablet Synthroid 88 Mcg Tablet Synthroid 100 Mcg Tablet Synthroid 112 Mcg Tablet Synthroid 125 Mcg Tablet Synthroid 137 Mcg Tablet Synthroid 150 Mcg Tablet Synthroid 175 Mcg Tablet Synthroid 200 Mcg Tablet Synthroid 300 Mcg Tablet SYNTHROID TABS 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 300MCG SYNTHROID TABS 25MCG, 50MCG, 75MCG, Synthroid Oral Tablet Levothyroxine Sodium
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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: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — — None
Elite Bronze Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver Tier 3 - Preferred Brand — — — None
Standard Gold Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Signature + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via levothyroxine sodium 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Brand-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Focus 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Tirosint 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Tirosint 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Tirosint 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 5000 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Silver
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Euthyrox 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Humana Dual Select H1036-307 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Signature (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Value Plus (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Prime (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Care (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Extra (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring True Choice (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Select (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Savings (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring Preferred Plus (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Choice (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Blue Medicare Essential (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Experience Health Medicare Advantage (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan II (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Assist Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5216-211 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Full Access H5525-034 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-049 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-050 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-070 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HumanaChoice H5525-083 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO) Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via levothyroxine sodium 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via levothyroxine sodium 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO) Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Tirosint 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via levothyroxine sodium 		Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Diabetes | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
AIAN Cost Share
via levothyroxine sodium 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Classic
via levothyroxine sodium 		Tier 2 - Generic — — — None
Secure
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Classic 4700
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via levothyroxine sodium 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via levothyroxine sodium 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Classic Standard
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Classic Standard
via levothyroxine sodium 		Tier 2 - Generic — — — None
Gold Classic Standard
via levothyroxine sodium 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via levothyroxine sodium 		Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 Tier 3 - Preferred Brand — — — None
Secure Tier 3 - Preferred Brand — — — None
Silver Classic Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — — None
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — — None
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — — None
AIAN Cost Share Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes Tier 3 - Preferred Brand — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Classic Standard Tier 3 - Preferred Brand — — — None
Silver Classic Standard Tier 3 - Preferred Brand — — — None
Gold Classic Standard Tier 3 - Preferred Brand — — — None
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via levothyroxine sodium 		Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 17 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard (No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard (No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard (No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard (No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Euthyrox 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Standard (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Standard (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Bronze Standard (No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Gold Standard (No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Silver Standard (No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Tirosint 		Tier 4 - Non-Preferred ✓ — — PA
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