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 |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze | 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 |
| Everyday Bronze | 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 |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + 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 Advantage 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Local 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 Value 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 Bronze CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver 4400 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Gold CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Silver CMS Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (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 Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Troy Medicare (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| 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 |
| Experience Health Medicare Advantage (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| 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 |
| Alignment Health AVA (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 |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | 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 Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Erickson Advantage Signature (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-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 |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | 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 |
| Erickson Advantage Champion (HMO-POS C-SNP) | 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 Enhanced (HMO) | 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 |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred (HMO) | 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 |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-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 |
| 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 CORE 001 NC (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| 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 |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Wellcare Simple Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H1036-307 (HMO D-SNP) | 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 |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5216-211 (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 |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-083 (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 |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
NC Medicaid PDL
1 planNC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 |
| NC State Health Plan - HDHP 2026 | Tier 2 - Non-Preferred Generic | ✓ | — | — | PA |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Simple Diabetes | 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 Elite Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Secure | with Atrium Health | 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 |
| Secure | Tier 3 - Preferred Brand | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Classic | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
| AIAN Cost Share | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 3 - Preferred Brand | — | — | — | None |
| Gold Classic Standard | 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 |
| Silver Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Bronze Classic Standard | Tier 3 - Preferred Brand | — | — | — | None |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Standard+ Dental + Vision (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, Dental + Vision, 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 Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, 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 |
| UHC Bronze Essential ($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 Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |