bosentan
Generic: Tracleer
62.5 mg, 125 mg — Suspension
Also known as:
bosentan oral tablet
bosentan tabs 62.5mg, 125mg; tbso 32mg
bosentan tab for oral susp 32 mg
bosentan tab 62.5 mg, 125 mg
Bosentan 62.5 Mg Tablet
Bosentan 125 Mg Tablet
bosentan tabs 62.5mg, 125mg
Bosentan Oral Tablet
Bosentan Oral Tablet Soluble
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
58 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Clear Silver with $0 Insulin Options
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield Federal
4 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Standard Option 2026
via Tracleer |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Local 2026
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Advantage 2026
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Care 2026
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Value 2026
via Tracleer |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 4400 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
Medicare Part D
108 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
NC Medicaid PDL
1 planNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - HDHP 2026
via Tracleer |
Not Covered | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Tracleer |
Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Tracleer |
Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Bronze Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |