dasatinib
Generic: Phyrago
20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 140 mg — Tablet
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.
Ambetter (Centene)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Streamlined Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Streamlined Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite 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 with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sprycel |
Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
5 plans| 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 |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Care 2026
via Sprycel |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Advantage 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 Value 2026
via Sprycel |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver 3600 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
Medicare Part D
172 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| PruittHealth Premier (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 |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| 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 |
| 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 Champion (HMO-POS C-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 |
| Liberty Medicare Advantage (HMO C-SNP) | 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 |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Healthy Blue + Medicare (HMO-POS D-SNP) | 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 |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring Preferred (HMO) | 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 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 |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| DEVOTED CHOICE 001 NC (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 |
| 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 - Diabetes and Heart (HMO C-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 |
| 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 |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| 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 Giveback Open (PPO) | 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 |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| 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 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 Chronic Care (HMO C-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 Value (HMO C-SNP) | 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 |
| Wellcare Simple (HMO-POS) | 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 Reserve (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 |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| 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 |
| 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 |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | 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 |
| 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 |
| 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 |
| 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 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 GIVEBACK 012 NC (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 |
| 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 |
| Humana Full Access H5525-034 (PPO) | 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 |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
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 |
|
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 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 Champion (HMO-POS C-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 |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - 70/30 Standard PPO 2026
via Sprycel |
Not Covered | — | — | — | None |
|
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 |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Bronze Elite + PCP Saver Plus | 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 |
| 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 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 |
| 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 |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | 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 |
| 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 |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
UnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, 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 Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |