cimetidine

Generic: Tagamet

200mg, 300mg, 400mg, 800mg — Tablet

Histamine2 (H2) Receptor Antagonists

Also known as: cimetidine oral Tagamet Cimetidine 300 Mg/5 Ml Oral Solution Cimetidine 200 Mg Tablet Cimetidine 300 Mg Tablet Cimetidine 400 Mg Tablet Cimetidine 800 Mg Tablet cimetidine tabs 200mg, 300mg, 400mg, 800mg cimetidine tabs 200mg, 300mg, 400mg, Cimetidine Oral Tablet
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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: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Tagamet 		Tier 2 - Generic — — — None
Everyday Bronze
via Tagamet 		Tier 2 - Generic — — — None
Elite Bronze
via Tagamet 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Tagamet 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via Tagamet 		Tier 2 - Generic — — — None
Signature Silver
via Tagamet 		Tier 2 - Generic — — — None
Signature Gold
via Tagamet 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 2 - Generic — — — None
Streamlined Silver Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options Tier 2 - Generic — — — None
Complete Gold
via Tagamet 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Tagamet 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via Tagamet 		Tier 2 - Generic — — — None
Streamlined Silver
via Tagamet 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Tagamet 		Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Signature Expanded Bronze Tier 2 - Generic — — — None
Signature Silver Tier 2 - Generic — — — None
Signature Gold Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Signature Silver with Atrium Health Tier 2 - Generic — — — None
Signature Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP) 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
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
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO) Tier 2 - Generic — — — None
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO) Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO) Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 2 - Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: CMS QHP JSON  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Gold Elite Saver Plus Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 18 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
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