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 Theophylline ER Oral Tablet Extended Release Theophylline Oral Elixir Theophylline Oral Solution
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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: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
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 Gold with Atrium Health + 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
Standard Expanded Bronze + Vision + Adult Dental 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
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Complete Gold 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
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
Standard Gold with Atrium Health
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Standard Silver 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
Everyday Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Elite Bronze
via Elixophyllin 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Elixophyllin 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold 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 Expanded Bronze with Atrium Health + Vision + Adult Dental
via Elixophyllin 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Aug 1, 2026  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Local 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 Value 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026
via Theophylline Er 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 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 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 Advantage 2026
via Theo-24 		Tier 3 - High Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Aug 21, 2026  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Theophylline Er 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Theophylline Er 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Aug 19, 2026  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community 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 Essential Plan (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Theophylline Er 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health Platinum (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Theophylline Er 		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
UHC Dual Complete NC-S001 (PPO D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare Choice (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare Essential (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via Theophylline Er 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Theophylline Er 		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 from UHC NC-0021 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Theophylline Er 		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
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) 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
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) 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
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - 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
Erickson Advantage Signature (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO) Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Theophylline Er 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Theophylline Er 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — — None
Blue Medicare Choice (HMO) Tier 2 - Generic — — — None
Blue Medicare Essential (HMO) Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Theophylline Er 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Theophylline Er 		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
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) 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
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) 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
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 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 016 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 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (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 Extra (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 Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (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
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
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via Theo-24 		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 Giveback Open (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
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 Reserve (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
HealthSpring True Choice (PPO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
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 Preferred Select (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Theo-24 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS)
via Theophylline Er 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via theophylline tb12 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 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: CMS QHP JSON  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Gold Elite Saver Plus Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Aug 25, 2026  ·  Checked: 5 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 1 - Preferred Generic — — — None
UHC Gold Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
54332NC0060010 Tier 1 - Preferred Generic — — — None
54332NC0060009 Tier 1 - Preferred Generic — — — None
54332NC0060008 Tier 1 - Preferred Generic — — — None
54332NC0030042 Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
54332NC0060010
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
54332NC0060009
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
54332NC0060008
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
54332NC0030042
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Silver Standard (No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Gold Standard (No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Elixophyllin 		Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Gold Standard (No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
54332NC0060010
via Theo-24 		Tier 4 - Non-Preferred — — — None
54332NC0060009
via Theo-24 		Tier 4 - Non-Preferred — — — None
54332NC0060008
via Theo-24 		Tier 4 - Non-Preferred — — — None
54332NC0030042
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
UHC Silver Standard (No Referrals)
via Theo-24 		Tier 4 - Non-Preferred — — — None
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