Xyvona

Generic: levorphanol tartrate

2 MG — Tablet

Opioid Agonist

Also known as: levorphanol tartrate
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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: 21 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze
via levorphanol tartrate 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Silver
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Gold
via levorphanol tartrate 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via levorphanol tartrate 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via levorphanol tartrate 		Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via levorphanol tartrate 		Tier 2 - Generic — — — None
Everyday Bronze
via levorphanol tartrate 		Tier 2 - Generic — — — None
Complete Gold
via levorphanol tartrate 		Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 21 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Essential + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via levorphanol tartrate 		Tier 2 - Generic ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 21 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via levorphanol tartrate 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via levorphanol tartrate 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via levorphanol tartrate 		Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 21 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AIAN Cost Share | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Classic Standard
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Gold Classic Standard
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Classic Standard | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Classic Standard | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Gold Classic Standard | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Elite + PCP Saver Plus
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Classic
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Secure
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Classic 4700
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple PCP Saver
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Gold Elite Saver Plus
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple Diabetes
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Secure | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Classic | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Simple Diabetes | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
AIAN Cost Share
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Bronze Classic Standard
via levorphanol tartrate 		Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 21 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Standard (No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard (No Referrals)
via levorphanol tartrate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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