theophylline

Generic: Elixophyllin

300 mg, 450 mg — Extended Release Tablet

COUGH/COLD/ALLERGY

Also known as: theophylline oral theophylline tab er 12hr 300 mg, 450 mg theophylline tab er 24hr 400 mg, 600 mg Theophylline 80 Mg/15 Ml Oral Solution Theophylline Er 100 Mg Tablet Theophylline Er 200 Mg Tablet Theophylline Er 300 Mg Tablet Theophylline Er 400 Mg Tablet Theophylline Er 450 Mg Tablet Theophylline Er 600 Mg Tablet
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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: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Gold
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Silver
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Elixophyllin 		Tier 2 - Generic — — — None
Elite Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Everyday Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold
via Elixophyllin 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Value 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Local 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS) Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO) Tier 2 - Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — — None
Blue Medicare Essential (HMO) Tier 2 - Generic — — — None
Blue Medicare Choice (HMO) Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (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 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 Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via theophylline tb12 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via theophylline tb12 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via theophylline tb12 		Tier 2 - Non-Preferred Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Theophylline Er 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Elixophyllin 		Tier 3 - Mid-Range Cost — — — None
UnitedHealthcare NC Individual & Family 2026 Tier 3 - Mid-Range Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Theo-24 		Tier 4 - Higher Cost — — — None
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