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 levothyroxine sodium

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

102 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Signature Silver with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Streamlined Silver via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Streamlined Silver with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Streamlined Silver via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Streamlined Silver with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold with Atrium Health via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx 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
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
Signature Expanded Bronze + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx 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
Signature Expanded Bronze via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Focused Silver with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Silver with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Signature Gold with Atrium Health via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Gold + 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
Focused Silver with Atrium Health + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Expanded Bronze + 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
Elite Bronze + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Complete Gold + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Streamlined Silver with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Gold with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Silver with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Expanded Bronze with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Complete Gold with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Focused Silver with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Elite Bronze with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Everyday Bronze with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Gold via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Silver via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Expanded Bronze via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Clear Silver with $0 Insulin Options via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Elite Bronze via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Everyday Bronze via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Complete Gold via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Silver + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Streamlined Silver via Synthroid	Tier 3 - Preferred Brand	—	—	—	None

AmeriHealth Caritas NC

31 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Synthroid	Brand-Preferred	—	—	—	None

Blue Cross Blue Shield Federal

10 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026 via levothyroxine sodium	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via levothyroxine sodium	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard 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 via Tirosint-Sol	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Tirosint-Sol	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

15 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Care 2026 via Synthroid	Tier 3 - High Cost Brand	—	—	—	None
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 Advantage 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 Local 2026 via Tirosint-Sol	Tier 3 - High Cost Brand	—	—	— Restricted Access	None
BCBSNC Blue Advantage 2026 via Synthroid	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Synthroid	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Local 2026 via Synthroid	Tier 3 - High Cost Brand	—	—	—	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
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

Cigna

40 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3000 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Euthyrox	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Synthroid	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Synthroid	Tier 4 - Non-Preferred	—	—	—	None

Medicare Part D

276 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
PruittHealth Premier (HMO I-SNP) via Synthroid	Tier 1 - Preferred Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) 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
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
UHC Dual Complete NC-S001 (PPO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Simple Open (PPO) 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 Giveback Open (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) 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
Wellcare Simple (HMO-POS) 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 Reserve (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
NHC Advantage (HMO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Senior Care (HMO I-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
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
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
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) 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
UHC Complete Care NC-27 (HMO-POS C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
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
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 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 GIVEBACK 012 NC (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
Longevity Health Plan (HMO I-SNP) 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
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
Erickson Advantage Signature (HMO-POS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-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
PruittHealth Premier (HMO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) 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
Alignment Health AVA (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring True Choice (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) 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
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
HealthTeam Advantage Plan I (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Synthroid	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
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 005 NC (PPO) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) 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 CHOICE 001 NC (PPO) 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 008 NC (PPO) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Synthroid	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Synthroid	Tier 2 - Generic	—	—	—	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
HealthTeam Advantage Diabetes & Heart Care (HMO 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 Chronic Care (HMO C-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (HMO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) 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
Wellcare Simple (HMO-POS) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Access (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
Wellcare Dual Liberty (HMO-POS D-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP) 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
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
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
UHC Complete Care NC-25 (HMO-POS C-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) 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
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
AARP Medicare Advantage from UHC NC-0012 (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
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 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 - Diabetes and Heart (HMO C-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
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
Wellcare Simple Open (PPO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Assist Open (PPO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Giveback Open (PPO) 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
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
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
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 Champion (HMO-POS C-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
Liberty Medicare Advantage (HMO C-SNP) 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
Alignment Health AVA (PPO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) 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
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
HealthSpring TotalCare Plus (HMO D-SNP) via levothyroxine sodium	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via levothyroxine sodium	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

NC State Health Plan

9 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 5 hours, 22 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 - 80/20 Plus PPO 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 levothyroxine sodium	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
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

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Secure via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via levothyroxine sodium	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Secure \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Classic \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AIAN Cost Share \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
AIAN Cost Share via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Elite + PCP Saver Plus via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Classic via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Secure via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Classic 4700 via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple PCP Saver via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Gold Elite Saver Plus via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Simple Diabetes via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Classic Standard via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Classic Standard via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Gold Classic Standard via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Silver Classic Standard \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
Gold Classic Standard \| with Atrium Health via Synthroid	Tier 3 - Preferred Brand	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 5 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via levothyroxine sodium	Tier 1 - Basic Core Formulary	✓	—	—	PA

UnitedHealthcare

68 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 5 hours, 21 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via levothyroxine sodium	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Euthyrox	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Synthroid	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	—	PA