Clomiphene

50 Mg — Tablet

Estrogen Agonist/Antagonist

Also known as: Clomiphene 50 Mg 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: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Silver
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via clomiphene citrate 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health
via Clomid 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Expanded Bronze with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Silver with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Standard Gold with Atrium Health
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Milophene 		Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via clomiphene citrate 		Tier 2 - Generic ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Clomid 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via clomiphene citrate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Standard Option 2026
via clomiphene citrate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Standard Option 2026
via Clomid 		Tier 1 - Generic ✓ — — PA
BCBS Federal Basic Option 2026
via Clomid 		Tier 1 - Generic ✓ — — PA
BCBS Federal Basic Option 2026
via clomiphene citrate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Focus 2026
via Clomid 		Tier 1 - Generic ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via clomiphene citrate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026
via clomiphene citrate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via clomiphene citrate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026
via clomiphene citrate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via clomiphene citrate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Clomid 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Clomid 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via clomiphene citrate 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Clomid 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via clomiphene citrate 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via clomiphene citrate 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026
via clomiphene citrate 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 80/20 Plus PPO 2026
via Milophene 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via Milophene 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 80/20 Plus PPO 2026
via Clomid 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via Clomid 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026
via Milophene 		Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026
via Clomid 		Tier 1 - Preferred Generic ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 8 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Standard (No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard (No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Standard (No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard (No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Standard (No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Milophene 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Standard (No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Bronze Standard (No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Standard (No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via clomiphene citrate 		Tier 3 - Preferred Brand ✓ — — PA
UHC Gold Standard (No Referrals)
via Clomid 		Tier 3 - Preferred Brand ✓ — — PA
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