Zilxi

Generic: minocycline hcl

1.5% — Foam

ROSACEA AGENTS

Also known as: ZILXI FOAM 1.5%
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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: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Signature + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via minocycline hcl 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via minocycline hcl 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via minocycline hcl 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via minocycline hcl 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — ✓ QL
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via minocycline hcl 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via minocycline hcl 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via minocycline hcl 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via minocycline hcl 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via minocycline hcl 		Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 6500 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Silver
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Bronze
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via minocycline hcl 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via minocycline hcl 		Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO)
via minocycline hcl 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via minocycline hcl 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via minocycline hcl 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via minocycline hcl 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Dual (HMO D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Value Plus (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Prime (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature Care (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Full Dual Care (HMO D-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Enhanced (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Enhanced (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Enhanced (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature Extra (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature Giveback (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Signature (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Chronic Care (HMO C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
Aetna Medicare Chronic Care Value (HMO C-SNP)
via minocycline hcl 		Tier 4 - Non-Preferred — ✓ — ST
HealthSpring True Choice (PPO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via minocycline hcl 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via minocycline hcl 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via minocycline hcl 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via minocycline hcl 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 16 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via minocycline hcl 		Tier 3 - Non-Formulary ✓ — — PA
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