desvenlafaxine succinate

25 mg, 50 mg, 100 mg — Extended Release Tablet

GENITOURINARY AGENTS - MISC.

Also known as: desvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg (base equiv), 100 mg (base equiv) Desvenlafaxine Succinate Er 25 Mg Tablet Desvenlafaxine Succinate Er 50 Mg Tablet Desvenlafaxine Succinate Er 100 Mg Tablet desvenlafaxine succinate tb24 25mg, 50mg, 100mg Desvenlafaxine Succinate ER Oral Tablet Extended Release
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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: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via desvenlafaxine succinate tb24 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via desvenlafaxine succinate tb24 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via desvenlafaxine succinate tb24 		Tier 1 - Preferred Generic — — — None
Source: CMS QHP JSON  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Classic Standard Tier 2 - Generic — — ✓ QL
Silver Classic Standard Tier 2 - Generic — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
AIAN Cost Share Tier 2 - Generic — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Classic Standard Tier 2 - Generic — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Classic | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — ✓ QL
Secure | with Atrium Health Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver Tier 2 - Generic — — ✓ QL
Bronze Classic 4700 Tier 2 - Generic — — ✓ QL
Secure Tier 2 - Generic — — ✓ QL
Silver Classic Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 11 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 3 - Preferred Brand — — ✓ QL
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