DEXLANSOPRAZOLE DR

60 MG

Proton Pump Inhibitor

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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: 14 hours, 41 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Silver with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Silver + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Gold + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Silver with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Streamlined Silver with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Streamlined Silver
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Silver
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Gold
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 14 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dexlansoprazole 		Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 14 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Silver 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Silver 3600 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Silver CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Connect Gold CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — ✓ QL
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — ✓ QL
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 14 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Wellcare Simple (HMO-POS)
via dexlansoprazole 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO)
via dexlansoprazole 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO)
via dexlansoprazole 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Reserve (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
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO)
via dexlansoprazole 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 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
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 14 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via dexlansoprazole 		Tier 3 - Non-Formulary — — — None
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