deferasirox

125 mg, 250 mg, 500 mg — Tablet

ANTIDOTES

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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: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental 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
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 Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze 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
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
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals 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
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Jadenu 		Tier 5 - Non-Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
BCBSNC Blue Advantage 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
BCBSNC Blue Value 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
BCBSNC Blue Care 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Gold RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Gold 1500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Silver Tier 5 - Specialty ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Bronze Tier 5 - Specialty ✓ — — PA
Connect Gold CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver 3600 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic ✓ — — PA
Senior Care (HMO I-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare (HMO) Tier 2 - Generic ✓ — — PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand ✓ — — PA
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
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
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
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health AVA (PPO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - 80/20 Plus PPO 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via Jadenu 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Jadenu 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Jadenu 		Not Covered — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 10 hours, 1 minute ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — — PA
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