TRAMADOL-ACETAMINOPHN

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: PDF  ·  Formulary date: Jul 24, 2026  ·  Checked: 11 hours, 41 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect myDiabetesCare Silver Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 11 hours, 41 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 360 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — ✓ 240 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — ✓ 240 per 30 days QL
Blue Medicare Choice (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Blue Medicare Essential (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health Platinum (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health smartHMO (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Alignment Health AVA (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Wellcare Assist Open (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Prime (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring True Choice (PPO) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring Preferred (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 2 - Generic — — ✓ 240 per 30 days QL
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