Aptiom

Generic: eslicarbazepine acetate

200MG, 400MG, 600MG, 800MG — Tablet

Carbamazepine Derivatives — Patients with a diagnosis of seizure disorder are exempt from T/F criteria and may use any carbamazepine product.

Also known as: eslicarbazepine acetate APTIOM TABS 200MG, 400MG, 600MG, 800MG Aptiom 200 Mg Tablet Aptiom 400 Mg Tablet Aptiom 600 Mg Tablet Aptiom 800 Mg Tablet APTIOM TABS 200MG, 400MG, 600MG, Aptiom Oral Tablet

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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)

34 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Signature Gold via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Elite Bronze with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Focused Silver with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Complete Gold via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Everyday Bronze via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Enhanced CHF Heart Care Silver $0 Rx Options via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Streamlined Silver with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Streamlined Silver via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Complete Gold with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Expanded Bronze with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Silver with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Gold with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Complete Gold + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Everyday Bronze + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Elite Bronze + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Expanded Bronze + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Silver + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Gold + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Silver with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Gold with Atrium Health + Vision + Adult Dental via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Silver via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Everyday Bronze with Atrium Health via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Elite Bronze via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Clear Silver with $0 Insulin Options via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
Signature Expanded Bronze via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL

AmeriHealth Caritas NC

21 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 2 - Generic	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Premier + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL

Blue Cross Blue Shield Federal

5 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026 via eslicarbazepine acetate	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via eslicarbazepine acetate	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via eslicarbazepine acetate	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

5 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 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
BCBSNC Blue Advantage 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

20 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3600 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver 5000 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze 5500 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze 6500 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze RD 6000 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze RD CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver RD 3500 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver RD 5000 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver RD CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver RD 2200 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze RD 5000 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Gold 1500 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect myDiabetesCare Silver	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect myDiabetesCare Bronze	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Gold CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Silver 3000 Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Gold RD CMS Standard	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL

Medicare Part D

177 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Community Plan (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
PruittHealth Premier (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
Longevity Health Plan (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
NHC Advantage (HMO I-SNP) via eslicarbazepine acetate	Tier 1 - Preferred Generic	✓	—	✓ 60 per 30 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via eslicarbazepine acetate	Tier 2 - Generic	—	—	✓ 60 per 30 days	QL
Senior Care (HMO I-SNP) via eslicarbazepine acetate	Tier 2 - Generic	✓	—	✓ 60 per 30 days	PA \| QL
Troy Medicare (HMO) via eslicarbazepine acetate	Tier 2 - Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP) via eslicarbazepine acetate	Tier 2 - Generic	✓	—	✓ 60 per 30 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via eslicarbazepine acetate	Tier 2 - Generic	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
DEVOTED CORE 001 NC (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Plan I (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Value Plus (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Prime (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Care (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (HMO) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via eslicarbazepine acetate	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health Platinum (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health NC Duals (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health smartHMO (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health Platinum Select (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Humana Full Access H5525-034 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice Giveback H5525-035 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice H5525-049 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice H5525-050 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice H5525-070 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Dual Select H5525-072 (PPO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice H5525-083 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Erickson Advantage Signature (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Erickson Advantage Freedom (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H6622-026 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H6622-057 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H6622-060 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H6622-061 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Alignment Health AVA (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring True Choice (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring TotalCare (HMO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring Preferred (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring TotalCare Plus (HMO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring Preferred Select (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring Preferred Savings (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HealthSpring Preferred Plus (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CORE 001 NC (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Extra (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Giveback (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Giveback Open (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Assist Open (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Simple Open (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Dual Select H1036-307 (HMO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H1036-233 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Humana Gold Plus H1036-137 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
HumanaChoice H5216-211 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
HumanaChoice Giveback H5216-017 (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Wellcare Simple (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Experience Health Medicare Advantage (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Blue Medicare Essential (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Blue Medicare Choice (HMO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Blue Medicare Enhanced (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Blue Medicare PPO Enhanced (PPO) via eslicarbazepine acetate	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Value Plus (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Prime (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Care (HMO)	Tier 5 - Specialty	—	—	✓ 60 per 30 days	QL

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via eslicarbazepine acetate	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026	Non-Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026 via eslicarbazepine acetate	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via eslicarbazepine acetate	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via eslicarbazepine acetate	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026	Tier 3 - Non-Preferred Brand	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic Standard via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic Standard \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700 \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Diabetes \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700 via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes via eslicarbazepine acetate	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL

UnitedHealthcare

17 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 22 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via eslicarbazepine acetate	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL