venlafaxine hcl

100 mg, 150 mg, 225 mg, 25 mg, 37.5 mg, 50 mg, 75 mg — Capsule

ANTIPSYCHOTICS

Also known as: venlafaxine hcl er oral capsule venlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 75 mg (base equivalent), 150 mg (base equivalent) venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base equivalent), 75 mg (base equivalent), 100 mg VENLAFAXINE HCL ER EFFEXOR XR venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base equivalent), 50 mg (base Venlafaxine HCl Oral Tablet Venlafaxine HCl ER Oral Capsule Extended Release Venlafaxine HCl ER Oral Tablet Extended Release
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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  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — ✓ — ST
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026
via Effexor XR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Effexor XR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Advantage 2026
via Effexor XR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Value 2026
via Effexor XR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Local 2026
via Effexor XR 		Tier 1 - Lowest Cost Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 4400 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 3500 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health Platinum (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health smartHMO (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health Platinum Select (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Wellcare Simple (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Wellcare Giveback Open (PPO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 90 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
HealthSpring True Choice (PPO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via VENLAFAXINE HCL ER 		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 Community Plan (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
HealthSpring Preferred (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via VENLAFAXINE HCL ER 		Tier 1 - Preferred Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — ✓ 90 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — ✓ 90 per 30 days QL
Blue Medicare Choice (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Blue Medicare Essential (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health smartHMO (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
Alignment Health AVA (PPO) Tier 2 - Generic — — ✓ 90 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 Plan I (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via VENLAFAXINE HCL ER 		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 VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Assist Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Assist Open (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO) Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO) Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO) Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Value Plus (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Prime (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Care (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring Preferred (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 2 - Generic — — ✓ 90 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO) Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO) Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO) Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO) Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice H5216-211 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Full Access H5525-034 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-049 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-050 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-070 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HumanaChoice H5525-083 (PPO)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via VENLAFAXINE HCL ER 		Tier 2 - Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) 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
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via VENLAFAXINE HCL ER 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
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 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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Effexor XR 		Preferred — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 17 hours, 57 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
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