clozapine

Generic: Versacloz

25 mg, 50 mg, 100 mg, 200 mg — Tablet

ANTIPSYCHOTICS

Also known as: clozapine oral tablet clozapine oral tablet dispersible Clozaril FazaClo clozapine tabs 25mg, 50mg, 100mg, 200mg; tbdp 12.5mg, 25mg, 200mg clozapine tab 25 mg, 50 mg, 100 mg, 200 mg Clozapine 25 Mg Tablet Clozapine 50 Mg Tablet Clozapine 100 Mg Tablet Clozapine 200 Mg Tablet Clozapine 12.5 Mg Odt Tablet Clozapine 25 Mg Odt Tablet Clozapine 150 Mg Odt Tablet Clozapine 100 Mg Odt Tablet Clozapine 200 Mg Odt Tablet clozapine tabs 25mg, 50mg, 100mg, 200mg; tbdp 25mg, 100mg, 150mg, 200mg clozapine tabs 25mg, 50mg, 100mg, 200mg; clozapine tabs 25mg, 50mg, 100mg, 200mg; tbdp 12.5mg, 25mg, 100mg, 150mg, 200mg cloZAPine Oral Tablet Disintegrating cloZAPine Oral Tablet
GoodRx Compare Prices

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: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Streamlined Silver Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze Tier 2 - Generic — — ✓ QL
Signature Silver Tier 2 - Generic — — ✓ QL
Signature Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 4 hours, 35 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 — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Versacloz 		Tier 4 - Non-Preferred — — ✓ QL
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 — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Clozaril 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Clozaril 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026
via Clozaril 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via Clozaril 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via Clozaril 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026
via Clozaril 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Clozaril 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via Versacloz 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Local 2026
via Versacloz 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Care 2026
via Versacloz 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Versacloz 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Value 2026
via Versacloz 		Tier 4 - Higher Cost Brand — — ✓ QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible 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 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 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
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Versacloz 		Tier 1 - Preferred Generic ✓ — ✓ 600 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic ✓ — ✓ 600 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic ✓ — ✓ 600 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic — — ✓ 540 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic — — ✓ 540 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic — — ✓ 540 per 30 days QL
NHC Advantage (HMO I-SNP)
via Versacloz 		Tier 1 - Preferred Generic ✓ — ✓ 600 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 120 per 30 days QL
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand ✓ — — PA
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Prime (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — — PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — — PA
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — — PA
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand ✓ — — PA
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — — PA
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 135 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Versacloz 		Tier 4 - Non-Preferred — — ✓ 600 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP)
via Versacloz 		Tier 4 - Non-Preferred ✓ — ✓ 600 per 30 days PA | QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Senior Care (HMO I-SNP)
via Versacloz 		Tier 4 - Non-Preferred ✓ — ✓ 600 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO)
via Versacloz 		Tier 4 - Non-Preferred — — ✓ 600 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Versacloz 		Tier 4 - Non-Preferred — — ✓ 600 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HealthSpring True Choice (PPO)
via Versacloz 		Tier 5 - Specialty — — — None
Alignment Health AVA (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-S2 (PPO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Wellcare Simple Open (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Assist Open (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Giveback Open (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty — — ✓ 540 per 30 days QL
Aetna Medicare Signature (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Prime (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature Care (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Enhanced (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Blue Medicare Choice (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Blue Medicare Essential (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Experience Health Medicare Advantage (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Wellcare Simple (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice H5216-211 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Alignment Health Platinum (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Alignment Health smartHMO (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Alignment Health Platinum Select (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Humana Full Access H5525-034 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice Giveback H5525-035 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice H5525-049 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice H5525-050 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice H5525-070 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
HumanaChoice H5525-083 (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Erickson Advantage Guardian (HMO-POS I-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Erickson Advantage Champion (HMO-POS C-SNP)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Erickson Advantage Freedom (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
Humana Gold Plus H6622-025 (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 540 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Versacloz 		Tier 5 - Specialty ✓ — — PA
HealthTeam Advantage Vitality Plan (PPO)
via Versacloz 		Tier 5 - Specialty — — ✓ 540 per 30 days QL
HealthTeam Advantage Plan II (PPO)
via Versacloz 		Tier 5 - Specialty — — ✓ 540 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via Versacloz 		Tier 5 - Specialty — — ✓ 540 per 30 days QL
HealthSpring Preferred Plus (HMO)
via Versacloz 		Tier 5 - Specialty — — — None
HealthSpring Preferred Savings (HMO)
via Versacloz 		Tier 5 - Specialty — — — None
HealthSpring Preferred Select (HMO)
via Versacloz 		Tier 5 - Specialty — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty — — — None
HealthSpring Preferred (HMO)
via Versacloz 		Tier 5 - Specialty — — — None
HealthSpring TotalCare (HMO D-SNP)
via Versacloz 		Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via Versacloz 		Tier 5 - Specialty ✓ — ✓ 600 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Versacloz 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Clozaril 		Non-Preferred — ✓ — ST
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Versacloz 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Clozaril 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Clozaril 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Clozaril 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Versacloz 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Versacloz 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | 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 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
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 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
Silver Classic | 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
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 4 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, 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 — — ✓ QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
Something not right?