Xyvona
Generic: levorphanol tartrate
2 MG — Tablet
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.
Ambetter (Centene)
68 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Complete Gold
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Enhanced Asthma/COPD Care Silver $0 Rx Options
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Everyday Bronze
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Elite Bronze
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Clear Silver with $0 Insulin Options
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Expanded Bronze
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Silver
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature 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 |
|
Signature Expanded Bronze with Atrium Health
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Silver with Atrium Health
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Gold with Atrium Health
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Enhanced Asthma/COPD Care Silver $0 Rx 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 |
|
Signature Expanded Bronze + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Silver + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Gold + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Silver with Atrium Health + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Signature Gold with Atrium Health + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Enhanced CHF Heart Care Silver $0 Rx Options
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Streamlined Silver with Atrium Health
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Streamlined Silver
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
|
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via levorphanol tartrate |
Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Signature Silver | Tier 2 - Generic | — | — | — | None |
| Signature Gold | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx 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 |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 2 - Generic | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 2 - Generic | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | — | None |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - 80/20 Plus PPO 2026
via levorphanol tartrate |
Not Covered | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via levorphanol tartrate |
Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via levorphanol tartrate |
Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
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 |
|
AIAN Cost Share | 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 |
|
Bronze Classic Standard
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 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 |
|
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 Diabetes | with Atrium Health
via levorphanol tartrate |
Tier 4 - Non-Preferred | — | — | ✓ | QL |
UnitedHealthcare
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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 Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, 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 Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, 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, HSA, $0 Insulin, Dental + Vision, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, 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 Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via levorphanol tartrate |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |