Bordetella pertussis filamentous hemagglutinin vaccine, inactivated

0.005 MG

Inactivated Bordetella Pertussis Vaccine

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

204 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 13 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Focused Silver with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Streamlined Silver via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Silver + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Signature Gold + Vision + Adult Dental via Adacel	Tier 0 - $0 Preventive	—	—	—	None

AmeriHealth Caritas NC

52 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 13 hours, 39 minutes ago

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 via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Daptacel	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Adacel	Brand-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Boostrix	Brand-Preferred	—	—	—	None

Blue Cross Blue Shield of NC

30 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 13 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Boostrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Adacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Local 2026 via Adacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Adacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Adacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Daptacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Daptacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Local 2026 via Daptacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Daptacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Daptacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Boostrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Boostrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Adacel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Boostrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Boostrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Infanrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Infanrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Local 2026 via Infanrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Infanrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Infanrix	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Quadracel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Quadracel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Local 2026 via Quadracel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Quadracel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Quadracel	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Advantage 2026 via Vaxelis	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Vaxelis	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Local 2026 via Vaxelis	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Care 2026 via Vaxelis	Tier A - ACA $0 Copay	—	—	—	None
BCBSNC Blue Value 2026 via Vaxelis	Tier A - ACA $0 Copay	—	—	—	None

Medicare Part D

700 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 13 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Humana Gold Plus H1036-233 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential 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 Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS)	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Daptacel	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Adacel	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health AVA (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Infanrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Boostrix	Tier 1 - Preferred Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Signature (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Freedom (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Liberty (HMO-POS) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
HealthSpring True Choice (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP) via Daptacel	Tier 3 - Preferred Brand	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Signature (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Freedom (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Liberty (HMO-POS) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
HealthSpring True Choice (PPO) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP) via Boostrix	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Signature (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Freedom (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Liberty (HMO-POS) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
HealthSpring True Choice (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
Senior Care (HMO I-SNP) via Infanrix	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
HealthSpring Preferred Plus (HMO) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Liberty (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Freedom (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Signature (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Adacel	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Signature (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Freedom (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Liberty (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 0.50 per 1 days	QL
HealthSpring True Choice (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Assist Open (PPO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Assist Open (PPO)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential (HMO)	Tier 6 - Specialty Plus	—	—	—	None
Experience Health Medicare Advantage (HMO)	Tier 6 - Specialty Plus	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare (HMO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Experience Health Medicare Advantage (HMO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential (HMO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare (HMO)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple Open (PPO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare (HMO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple Open (PPO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple (HMO-POS) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Assist Open (PPO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Assist Open (PPO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Giveback Open (PPO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare (HMO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Choice (HMO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential (HMO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Experience Health Medicare Advantage (HMO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Experience Health Medicare Advantage (HMO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential (HMO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Choice (HMO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple Open (PPO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple (HMO-POS) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Giveback Open (PPO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Giveback Open (PPO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple (HMO-POS) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple Open (PPO) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
Experience Health Medicare Advantage (HMO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential (HMO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Choice (HMO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Giveback Open (PPO) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Adacel	Tier 6 - Specialty Plus	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare (HMO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple Open (PPO)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Assist Open (PPO) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Infanrix	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Simple (HMO-POS) via Boostrix	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare PPO Enhanced (PPO)	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Essential Plus (HMO-POS)	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Enhanced (HMO-POS)	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Choice (HMO)	Tier 6 - Specialty Plus	—	—	—	None
Blue Medicare Choice (HMO) via Daptacel	Tier 6 - Specialty Plus	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 6 - Specialty Plus	—	—	—	None

NC State Health Plan

18 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 13 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026 via Quadracel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Daptacel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Daptacel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Daptacel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Vaxelis	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Vaxelis	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Infanrix	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Infanrix	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Vaxelis	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Quadracel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Quadracel	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Infanrix	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Boostrix	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Adacel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Adacel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Boostrix	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Adacel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Boostrix	Tier 3 - Non-Preferred Brand	—	—	—	None

Oscar Health

324 plans

Source: CMS QHP JSON · Formulary date: Oct 13, 2026 · Checked: 13 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
69803NC0010076 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Secure via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010076 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Quadracel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Secure via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010076 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Secure via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010076 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Infanrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010076 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
Secure via Daptacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Secure via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Boostrix	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic Standard \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Gold Classic Standard \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Secure via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Secure \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Classic \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010074 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010075 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010076 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010077 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010078 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010079 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010080 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010081 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010082 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010083 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010084 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010085 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Core Plan \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010108 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010109 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010110 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010111 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010112 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010113 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010114 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010115 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010116 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
69803NC0010117 via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Vaxelis	Tier 0 - $0 Preventive	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Adacel	Tier 0 - $0 Preventive	—	—	—	None

UnitedHealthcare

85 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 13 hours, 39 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 Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Infanrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Boostrix	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Adacel	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Daptacel	Tier 0 - $0 Preventive	—	—	✓	QL