acitretin
10 mg, 17.5 mg, 25 mg — Capsule
Also known as:
Soriatane
acitretin caps 10mg
acitretin caps 17.5mg, 25mg
acitretin cap 10 mg, 17.5 mg, 25 mg
Acitretin 10 Mg Capsule
Acitretin 17.5 Mg Capsule
Acitretin 25 Mg Capsule
acitretin caps 10mg, 17.5mg, 25mg
Acitretin Oral Capsule
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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)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Value 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Care 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver 3000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver 4400 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 4 - Non-Preferred | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Erickson Advantage Signature (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Platinum (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health smartHMO (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Platinum Select (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CORE 001 NC (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health AVA (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE 003 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE 005 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED CHOICE 008 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Experience Health Medicare Advantage (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
NC Medicaid PDL
1 planNC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 2 - Non-Preferred Generic | ✓ | — | — | PA |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 2 - Non-Preferred Generic | ✓ | — | — | PA |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 2 - Non-Preferred Generic | ✓ | — | — | PA |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Secure | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Diabetes | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Elite Saver Plus | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple PCP Saver | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic 4700 | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| AIAN Cost Share | Tier 3 - Preferred Brand | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Secure | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
UnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060008 | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060010 | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060009 | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0030042 | Tier 4 - Non-Preferred | — | — | — | None |