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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  ·  Checked: 6 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — ✓ ✓ ST | QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 6 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage 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 Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
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