FillMapBlue Connect Copay (PCP) 75/55 $2000 Standardized (S)

Does Blue Connect Copay (PCP) 75/55 $2000 Standardized (S) cover levothyroxine?

Blue Connect Copay (PCP) 75/55 $2000 Standardized (S)
19636-19636LA0240022-0 · ACA · ACA Marketplace
levothyroxine
levothyroxineunder Blue Connect Copay (PCP) 75/55 $2000 Standardized (S)
Covered — some forms require prior authorization
30 of 100 covered forms have a condition attached. Your plan has to approve it first — your doctor’s office handles it.
What you'd pay
$30per 30-day fill

Your plan’s deductible comes first — you pay the full price until it is met.

This is the standard amount. If you qualified for a cost-sharing reduction when you enrolled, set your level above and this will follow it.

Amount limit applies — you can still fill it, but your plan caps how much you get at a time. This plan's drug list records the cap without stating the amount — your pharmacy can tell you when they fill it.
Tier
Preferred brand
Approval first
Required
Try another first
No
Amount limit
Yes
Talk to your pharmacist or doctor before acting on anything here. They can see your full history and this page cannot. Never start, stop, or switch a medication based on it. Coverage rules change and plans make exceptions — your pharmacy can check your exact benefit in seconds.As of Sep 14, 2026 · CMS QHP machine-readable. Reference information, not medical advice and not a price.

Covered forms and strengths (100)

  • levothyroxine sodium 0.013 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.013 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.025 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.025 MG Oral Tablet
  • levothyroxine sodium 0.025 MG Oral Tablet [Euthyrox]
  • levothyroxine sodium 0.025 MG Oral Tablet [Levo-T]
  • levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl]
  • levothyroxine sodium 0.025 MG Oral Tablet [Synthroid]
  • levothyroxine sodium 0.025 MG Oral Tablet [Unithroid]
  • levothyroxine sodium 0.025 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.0375 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.0375 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.044 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.044 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.05 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.05 MG Oral Tablet
  • levothyroxine sodium 0.05 MG Oral Tablet [Euthyrox]
  • levothyroxine sodium 0.05 MG Oral Tablet [Levo-T]
  • levothyroxine sodium 0.05 MG Oral Tablet [Levoxyl]
  • levothyroxine sodium 0.05 MG Oral Tablet [Synthroid]
  • levothyroxine sodium 0.05 MG Oral Tablet [Unithroid]
  • levothyroxine sodium 0.05 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.0625 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.0625 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.075 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.075 MG Oral Tablet
  • levothyroxine sodium 0.075 MG Oral Tablet [Euthyrox]
  • levothyroxine sodium 0.075 MG Oral Tablet [Levo-T]
  • levothyroxine sodium 0.075 MG Oral Tablet [Levoxyl]
  • levothyroxine sodium 0.075 MG Oral Tablet [Synthroid]
  • levothyroxine sodium 0.075 MG Oral Tablet [Unithroid]
  • levothyroxine sodium 0.075 MG/ML Oral Solution [Tirosint]Approval firstAmount limit
  • levothyroxine sodium 0.088 MG Oral Capsule [Tirosint]Approval first
  • levothyroxine sodium 0.088 MG Oral Tablet
  • levothyroxine sodium 0.088 MG Oral Tablet [Euthyrox]
  • levothyroxine sodium 0.088 MG Oral Tablet [Levo-T]
  • levothyroxine sodium 0.088 MG Oral Tablet [Levoxyl]
  • levothyroxine sodium 0.088 MG Oral Tablet [Synthroid]
  • levothyroxine sodium 0.088 MG Oral Tablet [Unithroid]
  • levothyroxine sodium 0.088 MG/ML Oral Solution [Tirosint]Approval firstAmount limit

← All coverage for levothyroxine