Arynta

Generic: lisdexamfetamine dimesylate

Solution

Antihyperkinesis / Adhd

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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.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Expanded Bronze + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Silver + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Gold + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Everyday Bronze
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Clear Silver with $0 Insulin Options
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Complete Gold
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Expanded Bronze
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Silver
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Gold
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Everyday Bronze with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Elite Bronze with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Focused Silver with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Complete Gold with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Expanded Bronze with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Silver with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Standard Gold with Atrium Health
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Complete Gold + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Everyday Bronze + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Elite Bronze + Vision + Adult Dental
via lisdexamfetamine dimesylate 		Tier 2 - Generic — ✓ ✓ ST | QL
Source: CMS QHP JSON  ·  Checked: 1 hour, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Aug 7, 2026  ·  Checked: 1 hour, 33 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via lisdexamfetamine dimesylate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Standard Option 2026
via lisdexamfetamine dimesylate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Focus 2026
via lisdexamfetamine dimesylate 		Tier 1 - Generic ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 1 hour, 33 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP)
via lisdexamfetamine dimesylate 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via lisdexamfetamine dimesylate 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via lisdexamfetamine dimesylate 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via lisdexamfetamine dimesylate 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Select (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Savings (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Plus (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Simple (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 1 hour, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 1 hour, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via lisdexamfetamine dimesylate 		Tier 2 - Non-Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via lisdexamfetamine dimesylate 		Tier 2 - Non-Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via lisdexamfetamine dimesylate 		Tier 2 - Non-Preferred Generic ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 1 hour, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via lisdexamfetamine dimesylate 		Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 1 hour, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		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 lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via lisdexamfetamine dimesylate 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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