Avtozma
Generic: tocilizumab
80MG/4ML, 200MG/10ML — Vial
Also known as:
Avtozma Subcutaneous Solution Prefilled Syringe
tocilizumab-anoh
Avtozma Vial / Autoinjector
AVTOZMA SOLN 80MG/4ML, 200MG/10ML,
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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| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Complete Gold
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Streamlined Silver
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Streamlined Silver with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced CHF Heart Care Silver $0 Rx Options
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Expanded Bronze + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Silver + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Gold + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Silver with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Gold with Atrium Health + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Clear Silver with $0 Insulin Options
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Expanded Bronze
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Silver
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Gold
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Expanded Bronze with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Silver with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Signature Gold with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze + Vision + Adult Dental
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Value 2026 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| BCBSNC Blue Care 2026 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| BCBSNC Blue Local 2026 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| BCBSNC Blue Advantage 2026 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Cigna
60 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Connect Gold RD CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 6500 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 5500 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 5000 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 3600 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 3000 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Gold CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect myDiabetesCare Bronze
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect myDiabetesCare Silver
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Gold 1500 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD 5000 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD 6000 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 3500 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 5000 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD CMS Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 2200 Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 6500 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 5500 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 5000 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 3600 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver 3000 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Gold CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect myDiabetesCare Bronze
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect myDiabetesCare Silver
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Gold 1500 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD 5000 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD 6000 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze RD CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 3500 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 5000 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Silver RD 2200 Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Gold RD CMS Standard
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 3600 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Medicare Part D
84 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Actemra Actpen |
Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Actemra |
Tier 1 - Preferred Generic | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Troy Medicare (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Experience Health Medicare Advantage (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Essential (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Choice (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Enhanced (HMO-POS)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Troy Medicare (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Platinum (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health smartHMO (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Platinum Select (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health AVA (PPO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health AVA (PPO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Platinum Select (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health smartHMO (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 30 days | PA | QL |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 30 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 3.60 per 28 days | PA | QL |
|
Alignment Health Platinum (HMO)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Enhanced (HMO-POS)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Choice (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Blue Medicare Essential (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
|
Experience Health Medicare Advantage (HMO)
via Actemra Actpen |
Tier 5 - Specialty | ✓ | — | ✓ 3.6 per 28 days | PA | QL |
NC Medicaid PDL
1 planNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 70/30 Standard PPO 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Actemra |
Not Covered | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Actemra |
Not Covered | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via Actemra |
Not Covered | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Not Covered | — | — | — | None |
Oscar Health
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Bronze Classic Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus | with Atrium Health
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
TRICARE
2 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
TRICARE Uniform Formulary 2026
via tocilizumab |
Tier 3 - Non-Formulary | ✓ | — | — | PA |
|
TRICARE Uniform Formulary 2026
via tocilizumab-anoh |
Tier 3 - Non-Formulary | ✓ | — | — | PA |
UnitedHealthcare
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Actemra |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |