No prior authorization
Does Blue Cross Blue Shield (affiliate) require prior authorization for Levoxyl?
Blue Cross Blue Shield (affiliate) does not require prior authorization for Levoxyl on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
- This drug does not appear on any of this payer's Medicare Part D formularies. That means it is NOT COVERED under those plans — which is a different and generally worse outcome than requiring prior authorization. An exception or formulary-exception request may still be possible.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| levothyroxine sodium 0.137 MG Oral Tablet [Levoxyl]966194 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.15 MG Oral Tablet [Levoxyl]966200 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.175 MG Oral Tablet [Levoxyl]966204 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl]966157 | 269 / 269 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.05 MG Oral Tablet [Levoxyl]966164 | 269 / 269 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.075 MG Oral Tablet [Levoxyl]966170 | 269 / 269 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.088 MG Oral Tablet [Levoxyl]966175 | 237 / 269 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.112 MG Oral Tablet [Levoxyl]966184 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.125 MG Oral Tablet [Levoxyl]966190 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.2 MG Oral Tablet [Levoxyl]966211 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.1 MG Oral Tablet [Levoxyl]966283 | 0 / 269 | 0 | 0 | 0 | Not on formulary |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl]
Levoxyl has 11 products in the corpus; this table is for levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Anthem Dual Advantage (HMO D-SNP) | H5422-018 | 1 | No | No | No |
| Anthem Extra Help (HMO-POS) | H5422-013 | 1 | No | No | No |
| Anthem Full Dual Advantage (HMO D-SNP) | H5422-019 | 1 | No | No | No |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-010 | 1 | No | No | No |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-010 | 1 | No | No | No |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-011 | 1 | No | No | No |
| Anthem I CareMore Chronic Care (HMO-POS C-SNP) | H0544-004 | 2 | No | No | No |
| Anthem I CareMore Chronic Care (HMO-POS C-SNP) | H0544-010 | 2 | No | No | No |
| Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP) | H4161-014 | 2 | No | No | No |
| Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP) | H4161-015 | 2 | No | No | No |
| Anthem I CareMore Home Care (HMO I-SNP) | H0544-005 | 2 | No | No | No |
| Anthem I CareMore Kidney Care (HMO-POS C-SNP) | H0544-015 | 2 | No | No | No |
| Anthem I CareMore Kidney Care (HMO-POS C-SNP) | H0544-020 | 2 | No | No | No |
| Anthem I CareMore Lung Care (HMO-POS C-SNP) | H0544-014 | 2 | No | No | No |
| Anthem I CareMore Lung Care (HMO-POS C-SNP) | H0544-019 | 2 | No | No | No |
| Anthem I CareMore Lung Care 2 (HMO-POS C-SNP) | H4161-016 | 2 | No | No | No |
| Anthem I CareMore Lung Care 2 (HMO-POS C-SNP) | H4161-017 | 2 | No | No | No |
| Anthem I CareMore Medicare Advantage (HMO-POS) | H4161-011 | 2 | No | No | No |
| Anthem I CareMore Medicare Advantage (HMO-POS) | H4161-013 | 2 | No | No | No |
| Anthem I CareMore Medicare Advantage 2 (HMO-POS) | H0544-002 | 2 | No | No | No |
| Anthem I CareMore Premium Savings (HMO-POS) | H4161-012 | 2 | No | No | No |
| Anthem Kidney Care (HMO-POS C-SNP) | H5422-015 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-056 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-061 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-062 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-063 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-064 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-065 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-095 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-096 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H0544-108 | 1 | No | No | No |
| Anthem Medicare Advantage (HMO-POS) | H5422-011 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-002 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-003 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-004 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-005 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-006 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-007 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-009 | 1 | No | No | No |
| Anthem Prime (HMO-POS) | H4161-010 | 1 | No | No | No |
| Anthem Select (HMO-POS) | H0544-058 | 1 | No | No | No |
| Anthem Select (HMO-POS) | H0544-066 | 1 | No | No | No |
| Anthem Select (HMO-POS) | H0544-069 | 1 | No | No | No |
| Anthem Select (HMO-POS) | H0544-091 | 1 | No | No | No |
| Anthem Select (HMO-POS) | H0544-098 | 1 | No | No | No |
| Blue Advantage Choice (PPO) | H0104-016 | 3 | No | No | No |
| Blue Advantage Complete (PPO) | H0104-012 | 3 | No | No | No |
| Blue Advantage Complete (PPO) | H0104-014 | 3 | No | No | No |
| Blue Advantage Premier (PPO) | H0104-015 | 3 | No | No | No |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-009 | 3 | No | No | No |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-014 | 3 | No | No | No |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-014 | 3 | No | No | No |
| Blue Cross Medicare Advantage Comfort (PPO) | H5959-015 | 3 | No | No | No |
| Blue Cross Medicare Advantage Comfort (PPO) | H5959-016 | 3 | No | No | No |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-010 | 3 | No | No | No |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-010 | 3 | No | No | No |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-011 | 3 | No | No | No |
| Blue Cross Medicare Advantage Core (PPO) | H5959-012 | 3 | No | No | No |
| Blue Cross Medicare Advantage Core (PPO) | H5959-013 | 3 | No | No | No |
| Blue Cross Medicare Advantage Core (PPO) | H5959-013 | 3 | No | No | No |
| Blue Cross Medicare Advantage Secure (HMO) | H8547-001 | 3 | No | No | No |
| Blue Medicare Advantage Classic PPO (PPO) | H5900-008 | 2 | No | No | No |
| Blue Medicare Advantage Enhanced PPO (PPO) | H5900-004 | 2 | No | No | No |
| Blue Medicare Advantage PPO (PPO) | H5900-001 | 2 | No | No | No |
| Blue Medicare Choice (HMO) | H3449-026 | 3 | No | No | No |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 3 | No | No | No |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 3 | No | No | No |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 3 | No | No | No |
| Blue Medicare Essential (HMO) | H3449-027 | 3 | No | No | No |
| Blue Medicare Essential (HMO) | H3449-027 | 3 | No | No | No |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 3 | No | No | No |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 3 | No | No | No |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 3 | No | No | No |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 3 | No | No | No |
| Blue Medicare PPO Enhanced (PPO) | H3404-003 | 3 | No | No | No |
| Blue Medicare PPO Enhanced (PPO) | H3404-003 | 3 | No | No | No |
| Blue Medicare Rx Enhanced (PDP) | S5540-004 | 3 | No | No | No |
| Blue Medicare Rx Standard (PDP) | S5540-002 | 3 | No | No | No |
| Blue MedicareRx Essentials (PDP) | S5726-020 | 3 | No | No | No |
| Blue MedicareRx Plus (PDP) | S5726-014 | 3 | No | No | No |
| Blue MedicareRx Value (PDP) | S5726-013 | 3 | No | No | No |
| BlueCHiP for Medicare Access (HMO-POS) | H4152-022 | 3 | No | No | No |
| BlueCHiP for Medicare Enhanced (HMO-POS) | H4152-013 | 3 | No | No | No |
| BlueCHiP for Medicare Essential (HMO-POS) | H4152-023 | 3 | No | No | No |
| BlueCHiP for Medicare Extra (HMO-POS) | H4152-018 | 3 | No | No | No |
| BlueMedicare Complete Rx (PDP) | S5904-002 | 3 | No | No | No |
| BlueMedicare Premier Rx (PDP) | S5904-001 | 3 | No | No | No |
| BlueMedicare Select (PPO) | H5434-002 | 3 | No | No | No |
| BlueMedicare Select (PPO) | H5434-045 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-023 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-024 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-025 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-026 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-030 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-031 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-034 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-035 | 3 | No | No | No |
| BlueMedicare Value (PPO) | H5434-036 | 3 | No | No | No |
| BlueRI for Duals (HMO D-SNP) | H4152-021 | 3 | No | No | No |
| BlueRx Enhanced Plus (PDP) | S1030-001 | 3 | No | No | No |
Showing 100 of 269 covering plans.
Source
Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.
Levoxyl at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.