dasatinib

Generic: Phyrago

20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 140 mg — Tablet

ANTINEOPLASTICS

Also known as: dasatinib tabs 20mg, 50mg, 70mg, 80mg, 100mg, 140mg dasatinib tab 20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 140 mg Dasatinib 20 Mg Tablet Dasatinib 50 Mg Tablet Dasatinib 70 Mg Tablet Dasatinib 80 Mg Tablet Dasatinib 100 Mg Tablet Dasatinib 140 Mg Tablet PHYRAGO Dasatinib Oral Tablet
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals
via Sprycel 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026
via Sprycel 		Tier 5 - Non-Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026
via Phyrago 		Tier 5 - Non-Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Sprycel 		Tier 5 - Specialty ✓ — ✓ PA | QL
BCBSNC Blue Care 2026
via Sprycel 		Tier 5 - Specialty ✓ — ✓ PA | QL
BCBSNC Blue Local 2026
via Sprycel 		Tier 5 - Specialty ✓ — ✓ PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Sprycel 		Tier 5 - Specialty ✓ — ✓ PA | QL
BCBSNC Blue Advantage 2026
via Sprycel 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold RD CMS Standard Tier 5 - Specialty — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect myDiabetesCare Bronze Tier 5 - Specialty — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver 4400 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver 3500 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 5 - Specialty — — ✓ QL
Connect myDiabetesCare Silver Tier 5 - Specialty — — ✓ QL
Connect Bronze CMS Standard Tier 5 - Specialty — — ✓ QL
Connect Bronze RD CMS Standard Tier 5 - Specialty — — ✓ QL
Connect Gold CMS Standard Tier 5 - Specialty — — ✓ QL
Connect Silver RD CMS Standard Tier 5 - Specialty — — ✓ QL
Connect Silver CMS Standard Tier 5 - Specialty — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Select (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Savings (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Plus (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Giveback Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Platinum (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health smartHMO (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Platinum Select (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health AVA (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan II (PPO) Tier 5 - Specialty ✓ — — PA
HealthTeam Advantage Vitality Plan (PPO) Tier 5 - Specialty ✓ — — PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO) Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
Wellcare Dual Liberty Open (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Assist Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO) Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Phyrago 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring True Choice (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring TotalCare (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5216-211 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Full Access H5525-034 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice Giveback H5525-035 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-049 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-050 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-070 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-083 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Senior Care (HMO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Sprycel 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Sprycel 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Sprycel 		Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 5 - Specialty ✓ — ✓ PA | QL
Secure Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 13 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Standard (No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Standard (No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Standard (No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
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