atomoxetine
100 MG — Capsule
Also known as:
Strattera
Atomoxetine 10 Mg Capsule
Atomoxetine 18 Mg Capsule
Atomoxetine 25 Mg Capsule
Atomoxetine 40 Mg Capsule
Atomoxetine 60 Mg Capsule
Atomoxetine 80 Mg Capsule
Atomoxetine 100 Mg Capsule
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 |
|---|---|---|---|---|---|
| Standard Expanded Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Advantage 2026
via Strattera |
Tier 2 - Medium Cost Generic/Brand | — | — | ✓ | QL |
|
BCBSNC Blue Local 2026
via Strattera |
Tier 2 - Medium Cost Generic/Brand | — | — | ✓ | QL |
|
BCBSNC Blue Care 2026
via Strattera |
Tier 2 - Medium Cost Generic/Brand | — | — | ✓ | QL |
|
BCBSNC Blue Value 2026
via Strattera |
Tier 2 - Medium Cost Generic/Brand | — | — | ✓ | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Strattera |
Tier 2 - Medium Cost Generic/Brand | — | — | ✓ | QL |
Cigna
1 planMedicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 30 per 30 days | QL |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Choice (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Experience Health Medicare Advantage (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |