Diastat AcuDial Rectal

Generic: Diazepam

10 MG — Gel

Also known as: Diastat AcuDial Rectal Gel Diazepam
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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: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Gold with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via diazepam 		Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via diazepam 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Valtoco 		Tier 3 - Non-Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Valtoco 		Tier 3 - Non-Preferred Brand ✓ — — PA
BCBS Federal Standard Option 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jun 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via diazepam 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via diazepam 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via diazepam 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via diazepam 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via diazepam 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Value 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Care 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3500 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via diazepam 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via diazepam 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via diazepam 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via diazepam 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: May 13, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic ✓ — ✓ 10 per 30 days PA | QL
NHC Advantage (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP)
via diazepam 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via diazepam 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via diazepam 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via diazepam 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via diazepam 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via diazepam 		Tier 3 - Preferred Brand — — ✓ 10 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP)
via diazepam 		Tier 3 - Preferred Brand — — ✓ 10 per 30 days QL
Wellcare Assist Open (PPO)
via Valtoco 		Tier 3 - Preferred Brand ✓ — ✓ 10 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP)
via Valtoco 		Tier 3 - Preferred Brand ✓ — ✓ 10 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP)
via Valtoco 		Tier 3 - Preferred Brand ✓ — ✓ 10 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via Valtoco 		Tier 3 - Preferred Brand ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Enhanced (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Enhanced (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Enhanced (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring Preferred (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HumanaChoice H5525-049 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Aetna Medicare Signature Care (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Prime (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Value Plus (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Senior Care (HMO I-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Wellcare Simple Open (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Wellcare Simple (HMO-POS)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Wellcare Giveback Open (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Choice (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Essential (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Experience Health Medicare Advantage (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Blue Medicare Choice (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Blue Medicare Essential (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Experience Health Medicare Advantage (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
Alignment Health Platinum (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health smartHMO (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Platinum Select (HMO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health AVA (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Troy Medicare (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Enhanced (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Prime (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Signature Care (HMO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
HumanaChoice H5525-070 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via diazepam 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via diazepam 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HumanaChoice H5216-211 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring True Choice (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring TotalCare (HMO D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring Preferred (HMO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring Preferred Select (HMO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring Preferred Savings (HMO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HealthSpring Preferred Plus (HMO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Alignment Health Platinum (HMO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health smartHMO (HMO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health Platinum Select (HMO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Alignment Health AVA (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthTeam Advantage Plan II (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Full Access H5525-034 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice H5525-049 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice H5525-050 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice H5525-070 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice H5525-083 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Valtoco 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Libervant Buccal 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Valtoco 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Libervant Buccal 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Libervant Buccal 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Libervant Buccal 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Valtoco 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Valtoco 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via diazepam 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via diazepam 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via diazepam 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic
via diazepam 		Tier 3 - Preferred Brand — — — None
Secure
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Classic 4700
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver
via diazepam 		Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes
via diazepam 		Tier 3 - Preferred Brand — — — None
Secure | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Classic | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
AIAN Cost Share
via diazepam 		Tier 3 - Preferred Brand — — — None
AIAN Cost Share | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Classic Standard
via diazepam 		Tier 3 - Preferred Brand — — — None
Gold Classic Standard
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Classic Standard | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Silver Classic Standard | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Gold Classic Standard | with Atrium Health
via diazepam 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus
via diazepam 		Tier 3 - Preferred Brand — — — None
Source: Excel (XLSX)  ·  Formulary date: May 29, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via diazepam 		Tier 1 - Basic Core Formulary — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard (No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Standard (No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Standard (No Referrals)
via diazepam 		Tier 3 - Preferred Brand — — ✓ QL
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