deferasirox

125 mg, 250 mg, 500 mg — Tablet

ANTIDOTES

Also known as: deferasirox granules deferasirox oral packet deferasirox oral tablet deferasirox oral tablet soluble deferasirox tabs 90mg, 180mg, 360mg; tbso 125mg, 250mg, 500mg deferasirox tab for oral susp 125 mg, 250 mg, 500 mg Deferasirox 90 Mg Granule Packet Deferasirox 180 Mg Granule Packet Deferasirox 360 Mg Granule Packet Deferasirox 90 Mg Tablet Deferasirox 180 Mg Tablet Deferasirox 360 Mg Tablet Deferasirox 125 Mg Tablet For Suspension Deferasirox 250 Mg Tablet For Suspension Deferasirox 500 Mg Tablet For Suspension deferasirox tabs 90mg, 180mg, 360mg; tbso Deferasirox Oral Tablet Deferasirox Granules Oral Packet Deferasirox Oral Tablet Soluble
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: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + 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
Focused Silver with Atrium Health + Vision + Adult Dental 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
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard 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
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Standard 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
Everyday Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 43 minutes 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: Jul 1, 2026  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 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
BCBSNC Blue Care 2026
via Exjade 		Tier 2 - Medium Cost Generic/Brand ✓ — ✓ PA | QL
BCBSNC Blue Local 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
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Bronze Tier 5 - Specialty ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver 3500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver 4400 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Silver CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect Bronze CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Bronze RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Gold RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Gold CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver RD CMS Standard Tier 5 - Specialty ✓ — — PA
Connect Silver 3000 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Silver Tier 5 - Specialty ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — — PA
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
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Troy Medicare (HMO) Tier 2 - Generic ✓ — — PA
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic ✓ — — PA
Senior Care (HMO I-SNP) Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — — PA
UHC Complete Care NC-25 (HMO-POS C-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-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
AARP Medicare Advantage from UHC NC-26 (HMO-POS) 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 Freedom (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Erickson Advantage Liberty (HMO-POS) 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
UHC Nursing Home Plan NC-F001 (PPO I-SNP) 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 Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED CORE 001 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
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-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
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred ✓ — — PA
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health AVA (PPO) 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (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 Extra (PPO) 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 (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO) 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
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Access (HMO-POS D-SNP) 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
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-137 (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 H1036-233 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus Giveback H1036-318 (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 H1036-335 (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5216-211 (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 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
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - HDHP 2026 Tier 4 - Specialty Generic ✓ — — PA
NC State Health Plan - 80/20 Plus PPO 2026
via Jadenu 		Not Covered — — — None
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
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 13 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, 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, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
Something not right?