Alvesco

Generic: ciclesonide

0.16 MG — Inhaler

Anti-inflammatories, Inhaled Corticosteroids

Also known as: ciclesonide Alvesco 80 Mcg Inhaler Alvesco 160 Mcg Inhaler

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

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Expanded Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver	Tier 4 - Non-Preferred	✓	—	—	PA

Blue Cross Blue Shield Federal

1 plan

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Omnaris	Tier 2 - Preferred Brand	—	—	—	None

Cigna

40 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 2200 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Bronze	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Silver	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold RD CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze RD CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Gold CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver RD CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze 6500 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver 3000 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver RD 5000 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver 4400 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze 7000 HSA Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver RD 3500 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze RD 5000 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver 3500 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze RD 6000 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze 5500 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect myDiabetesCare Bronze via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Gold 1500 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Silver RD 2200 Indiv Med Deductible via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect Bronze CMS Standard via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST
Connect myDiabetesCare Silver via Zetonna	Tier 4 - Non-Preferred	—	✓	—	ST

Medicare Part D

44 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	✓ 12.2 per 30 days	QL
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 12.2 per 30 days	QL
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 12.2 per 30 days	QL
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 12.2 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 12.2 per 30 days	QL
Senior Care (HMO I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 12.2 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 12.2 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.20 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 4 - Non-Preferred	—	—	✓ 12.2 per 30 days	QL

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Omnaris	Non-Preferred	—	✓	—	ST
NC Medicaid Preferred Drug List 2026 via Zetonna	Non-Preferred	—	✓	—	ST

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Classic Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic 4700	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple PCP Saver	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Elite Saver Plus	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic 4700 \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Diabetes \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AIAN Cost Share	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Diabetes \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Elite Saver Plus \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple PCP Saver \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Diabetes \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic 4700 \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Secure \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Diabetes via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Elite Saver Plus via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple PCP Saver via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic 4700 via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Secure via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Elite + PCP Saver Plus via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Classic Standard \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic Standard \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic Standard \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Classic Standard via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic Standard via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic Standard via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Diabetes	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AIAN Cost Share via Omnaris	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via ciclesonide	Tier 3 - Non-Formulary	✓	—	✓	PA \| QL

UnitedHealthcare

13 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 21 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard (No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Standard (No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Standard (No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL