temazepam

7.5mg, 15mg, 22.5mg, 30mg — Capsule

HYPNOTICS

Also known as: temazepam caps 7.5mg, 15mg, 22.5mg, 30mg temazepam cap 15 mg, 30 mg Temazepam 7.5 Mg Capsule Temazepam 15 Mg Capsule Temazepam 22.5 Mg Capsule Temazepam 30 Mg Capsule RESTORIL Temazepam Oral Capsule
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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: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze Tier 2 - Generic — — ✓ QL
Standard Silver Tier 2 - Generic — — ✓ QL
Standard Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 1 - Generic — — ✓ QL
BCBS Federal Basic Option 2026 Tier 1 - Generic — — ✓ QL
BCBS Federal Focus 2026 Tier 1 - Generic — — ✓ QL
BCBS Federal Basic Option 2026
via Restoril 		Tier 3 - Non-Preferred Brand — — ✓ QL
BCBS Federal Standard Option 2026
via Restoril 		Tier 3 - Non-Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Restoril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Restoril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Restoril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Restoril 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Restoril 		Tier 1 - Lowest Cost Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic ✓ — ✓ 30 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 365 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Restoril 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - HDHP 2026 Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - HDHP 2026
via Restoril 		Tier 3 - Non-Preferred Brand ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via Restoril 		Tier 3 - Non-Preferred Brand ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via Restoril 		Tier 3 - Non-Preferred Brand ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Classic | with Atrium Health Tier 2 - Generic — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — ✓ QL
Secure | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver Tier 2 - Generic — — ✓ QL
Bronze Classic 4700 Tier 2 - Generic — — ✓ QL
Secure Tier 2 - Generic — — ✓ QL
Silver Classic Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Classic Standard Tier 2 - Generic — — ✓ QL
Silver Classic Standard Tier 2 - Generic — — ✓ QL
Bronze Classic Standard Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — ✓ QL
AIAN Cost Share Tier 2 - Generic — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — ✓ QL
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary — — — None
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 18 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Standard (No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Standard (No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Standard (No Referrals) Tier 1 - Preferred Generic — — ✓ QL
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