Besivance

Generic: besifloxacin

6 MG — Suspension

HEMATOLOGICAL AGENTS - MISC.

Also known as: BESIVANCE SUSP .6% besifloxacin Besivance Ophthalmic Suspension
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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: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Streamlined Silver
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Streamlined Silver with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Clear Silver with $0 Insulin Options
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Expanded Bronze
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Silver
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Gold
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Everyday Bronze with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Elite Bronze with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Focused Silver with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Complete Gold with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Expanded Bronze with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Silver with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Gold with Atrium Health
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Silver with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Gold + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Silver + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Elite Bronze + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Complete Gold + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Everyday Bronze
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Elite Bronze
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Complete Gold
via besifloxacin 		Tier 2 - Generic ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze Tier 4 - Non-Preferred ✓ — — PA
Signature Silver Tier 4 - Non-Preferred ✓ — — PA
Signature Gold Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred ✓ — — PA
Complete Gold Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via besifloxacin 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via besifloxacin 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via besifloxacin 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 2 - Non-Preferred Generic — — — None
Source: CMS QHP JSON  ·  Checked: 15 hours, 17 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred — — — None
Gold Elite Saver Plus | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
AIAN Cost Share Tier 4 - Non-Preferred — — — None
AIAN Cost Share | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred — — — None
Silver Classic Tier 4 - Non-Preferred — — — None
Secure Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver Tier 4 - Non-Preferred — — — None
Gold Elite Saver Plus Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes Tier 4 - Non-Preferred — — — None
Bronze Classic Standard Tier 4 - Non-Preferred — — — None
Silver Classic Standard Tier 4 - Non-Preferred — — — None
Gold Classic Standard Tier 4 - Non-Preferred — — — None
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
Secure | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Classic | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred — — — None
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