Clenpiq

Generic: citric acid

68.6 MG — Solution

Also known as: citric acid CLENPIQ SOL

Coverage by Insurer

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

Ambetter (Centene)

116 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold with Atrium Health via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Complete Gold via Phexxi	Tier 0 - $0 Preventive	—	—	—	None
Everyday Bronze via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Clear Silver with $0 Insulin Options via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Silver + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Standard Gold + Vision + Adult Dental via Phexx	Tier 0 - $0 Preventive	—	—	—	None
Elite Bronze with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Standard Gold via citric acid	Tier 2 - Generic	—	—	—	None
Standard Silver via citric acid	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze via citric acid	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Silver + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Gold + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Complete Gold via citric acid	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via citric acid	Tier 2 - Generic	—	—	—	None
Everyday Bronze via citric acid	Tier 2 - Generic	—	—	—	None
Elite Bronze via citric acid	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via citric acid	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Silver + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Gold + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Complete Gold via Cytra 2	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Cytra 2	Tier 2 - Generic	—	—	—	None
Everyday Bronze via Cytra 2	Tier 2 - Generic	—	—	—	None
Elite Bronze via Cytra 2	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Silver via Cytra 2	Tier 2 - Generic	—	—	—	None
Standard Gold via Cytra 2	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Cytra 2	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via citric acid	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via citric acid	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via Cytra 2	Tier 2 - Generic	—	—	—	None

AmeriHealth Caritas NC

30 plans

Source: CMS QHP JSON · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Bronze Premier + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Premier + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Premier + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Premier + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Phexxi	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Premier + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Phexx	Brand-Preferred	—	—	✓	QL

Blue Cross Blue Shield Federal

2 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

5 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 14 hours, 22 minutes ago

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

Cigna

80 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 3500 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Phexxi	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Phexx	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Phexx	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Phexxi	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Oracit	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Renacidin Irrigation	Tier 4 - Non-Preferred	—	—	—	None

Medicare Part D

64 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
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
Erickson Advantage Liberty (HMO-POS)	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 3 - Preferred Brand	—	—	—	None
Erickson Advantage Freedom (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (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-0015 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (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 from UHC NC-0012 (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
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	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
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (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
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	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 Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 4 - Non-Preferred	—	—	—	None

NC State Health Plan

12 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Phexx	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Phexx	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Phexx	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 0 - $0 Copay (ACA Preventive)	—	—	—	None
NC State Health Plan - HDHP 2026 via Oracit	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Renacidin Irrigation	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Renacidin Irrigation	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Renacidin Irrigation	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Oracit	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Oracit	Tier 3 - Non-Preferred Brand	—	—	—	None

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Classic Standard \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Gold Classic Standard via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Classic Standard via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Classic Standard via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Classic via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Secure via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Secure \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple Diabetes via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Classic 4700 via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple PCP Saver via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Gold Elite Saver Plus via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Gold Elite Saver Plus \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Classic \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
AIAN Cost Share via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
AIAN Cost Share \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
Silver Classic	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Elite Saver Plus	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes	Tier 3 - Preferred Brand	—	—	✓	QL
Secure \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Elite Saver Plus \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
AIAN Cost Share	Tier 3 - Preferred Brand	—	—	✓	QL
AIAN Cost Share \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus	Tier 3 - Preferred Brand	—	—	✓	QL
Secure	Tier 3 - Preferred Brand	—	—	✓	QL

UnitedHealthcare

39 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 14 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard (No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ Dental + Vision (No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard (No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Standard (No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard (No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Standard (No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Standard+ Dental + Vision (No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Phexxi	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Phexx	Tier 0 - $0 Preventive	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None