Does Keystone Health Plan Central, INC. require prior authorization for Levoxyl?
Keystone Health Plan Central, INC. 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 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.15 MG Oral Tablet [Levoxyl]966200 | 0 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.175 MG Oral Tablet [Levoxyl]966204 | 0 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl]966157 | 7 / 7 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.05 MG Oral Tablet [Levoxyl]966164 | 7 / 7 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.075 MG Oral Tablet [Levoxyl]966170 | 7 / 7 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.088 MG Oral Tablet [Levoxyl]966175 | 7 / 7 | 0 | 0 | 0 | No prior authorization |
| levothyroxine sodium 0.112 MG Oral Tablet [Levoxyl]966184 | 0 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.125 MG Oral Tablet [Levoxyl]966190 | 0 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.2 MG Oral Tablet [Levoxyl]966211 | 0 / 7 | 0 | 0 | 0 | Not on formulary |
| levothyroxine sodium 0.1 MG Oral Tablet [Levoxyl]966283 | 0 / 7 | 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 |
|---|---|---|---|---|---|
| Capital Blue Cross Essential (HMO) | H3962-022 | 3 | No | No | No |
| Capital Blue Cross Essential (HMO) | H3962-022 | 3 | No | No | No |
| Capital Blue Cross Essential (HMO) | H3962-022 | 3 | No | No | No |
| Capital Blue Cross Essential (HMO) | H3962-022 | 3 | No | No | No |
| Capital Blue Cross Essential (HMO) | H3962-022 | 3 | No | No | No |
| Capital Blue Cross Premier (HMO) | H3962-001 | 3 | No | No | No |
| Capital Blue Cross Value (HMO) | H3962-004 | 3 | No | No | No |
- 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.