ciclesonide

Generic: Alvesco

37 mcg/actuation, 50 mcg — Spray

NASAL ALLERGY AGENTS

Also known as: OMNARIS ZETONNA
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver
via Alvesco 		Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Omnaris 		Tier 2 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 2200 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver 3500 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver 4400 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible
via Alvesco 		Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze RD CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Gold CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver RD CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze 6500 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver 3000 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver RD 5000 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver 4400 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze 7000 HSA Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver RD 3500 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze RD 5000 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver 3500 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze RD 6000 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze 5500 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect myDiabetesCare Bronze
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Gold 1500 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Silver RD 2200 Indiv Med Deductible
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect Bronze CMS Standard
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Connect myDiabetesCare Silver
via Zetonna 		Tier 4 - Non-Preferred — ✓ — ST
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Dual Plan (HMO D-SNP)
via Alvesco 		Tier 1 - Preferred Generic — — ✓ 12.2 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via Alvesco 		Tier 1 - Preferred Generic — — ✓ 12.2 per 30 days QL
NHC Advantage (HMO I-SNP)
via Alvesco 		Tier 1 - Preferred Generic — — ✓ 12.2 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via Alvesco 		Tier 1 - Preferred Generic — — ✓ 12.2 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Alvesco 		Tier 1 - Preferred Generic — — ✓ 12.2 per 30 days QL
Senior Care (HMO I-SNP)
via Alvesco 		Tier 3 - Preferred Brand — — ✓ 12.2 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP)
via Alvesco 		Tier 3 - Preferred Brand — — ✓ 12.2 per 30 days QL
Aetna Medicare Signature (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Value Plus (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Prime (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature Care (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Enhanced (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Enhanced (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Enhanced (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.20 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Alvesco 		Tier 4 - Non-Preferred — — ✓ 12.2 per 30 days QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Alvesco 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Omnaris 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Zetonna 		Non-Preferred — ✓ — ST
Source: CMS QHP JSON  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic Standard
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Diabetes | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Elite Saver Plus | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple PCP Saver | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Diabetes | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic 4700 | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Secure | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Diabetes
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Elite Saver Plus
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple PCP Saver
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic 4700
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Secure
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Elite + PCP Saver Plus
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Classic Standard | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic Standard | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic Standard | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Classic Standard
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic Standard
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic Standard
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Diabetes
via Alvesco 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AIAN Cost Share
via Omnaris 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 14 hours, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard (No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard (No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Standard (No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Alvesco 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
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