Unithroid

Generic: levothyroxine

25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg — Tablet

(Thyroid)

Also known as: levothyroxine sodium Unithroid 25 Mcg Tablet Unithroid 50 Mcg Tablet Unithroid 75 Mcg Tablet Unithroid 88 Mcg Tablet Unithroid 100 Mcg Tablet Unithroid 112 Mcg Tablet Unithroid 125 Mcg Tablet Unithroid 137 Mcg Tablet Unithroid 150 Mcg Tablet Unithroid 175 Mcg Tablet Unithroid 200 Mcg Tablet Unithroid 300 Mcg Tablet unithroid tabs 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg Unithroid Tabs 25mcg, 50mcg, 75mcg, 88mcg,
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Coverage by Insurer

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