Tirosint

Generic: levothyroxine sodium

13MCG, 25MCG, 37.5MCG, 44MCG, 50MCG, 62.5MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG — Capsule

THYROID AGENTS

Also known as: TIROSINT CAPS 13MCG, 25MCG, 50MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG TIROSINT CAPS 13MCG, 25MCG, 37.5MCG, 44MCG, 50MCG, 62.5MCG, 75MCG, 88MCG, 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG TIROSINT CAPS 175MCG, 200MCG
GoodRx Compare Prices

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: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + 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 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
Focused Silver with Atrium Health + 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
Standard Expanded Bronze + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver + 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
Complete Gold 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
Elite Bronze with Atrium Health + 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
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
Complete Gold
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
Everyday Bronze
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Gold
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Elite Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Focused Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Everyday Bronze + Vision + Adult Dental
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
Standard Gold with Atrium Health
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
Complete Gold + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Everyday Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Elite Bronze
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Clear Silver with $0 Insulin Options
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Gold + 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 Silver with Atrium Health + Vision + Adult Dental
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Complete Gold + Vision + Adult Dental
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
Standard Gold with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Silver with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Standard Expanded Bronze with Atrium Health
via Euthyrox 		Tier 1 - Preferred Generic — — — None
Complete Gold with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Synthroid 		Tier 3 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
via levothyroxine sodium 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Synthroid 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Tirosint-Sol 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Tirosint-Sol 		Tier 3 - High Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 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 Care 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Local 2026
via Synthroid 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026
via Euthyrox 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Synthroid 		Tier 3 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
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
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
HealthTeam Advantage Plan I (PPO)
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
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 Dual Select H1036-307 (HMO D-SNP)
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
Aetna Medicare Signature (HMO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
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
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
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
AARP Medicare Advantage from UHC NC-0001 (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
HealthSpring True Choice (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
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)
via Synthroid 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Synthroid 		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)
via Synthroid 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Synthroid 		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
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
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
Wellcare Simple Open (PPO)
via levothyroxine sodium 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (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
Wellcare Giveback Open (PPO)
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
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
Erickson Advantage Signature (HMO-POS)
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
UHC Complete Care NC-28 (HMO-POS C-SNP)
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
Erickson Advantage Champion (HMO-POS C-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
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Synthroid 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Synthroid 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Synthroid 		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 (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Synthroid 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Synthroid 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Synthroid 		Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Synthroid 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Synthroid 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026
via levothyroxine sodium 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via levothyroxine sodium 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jan 5, 2026  ·  Checked: 16 hours, 11 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: Jan 1, 2026  ·  Checked: 16 hours, 11 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via levothyroxine sodium 		Tier 2 - Lower Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Synthroid 		Tier 3 - Mid-Range Cost — — — None
UnitedHealthcare NC Individual & Family 2026
via Tirosint-Sol 		Unknown ✓ — — PA
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