diazepam

Generic: Libervant Buccal

2 mg, 5 mg, 10 mg — Tablet

GENITOURINARY AGENTS - MISC.

Also known as: diazepam oral concentrate diazepam oral solution diazepam oral tablet DIAZEPAM SOLN 5MG/ML diazepam oral soln 1 mg/ml diazepam tab 2 mg, 5 mg, 10 mg Diazepam 5 Mg/Ml Oral Concentrate Diazepam 25 Mg/5 Ml Oral Concentrate Diazepam 5 Mg/5 Ml Oral Solution Diazepam 2.5 Mg Rectal Gel (2Pk) Diazepam 10 Mg Rectal Gel (2Pk) Diazepam 20 Mg Rectal Gel (2Pk) Diazepam 10 Mg Rectal Gel Syringe Diazepam 20 Mg Rectal Gel Syringe Diazepam 2 Mg Tablet Diazepam 5 Mg Tablet Diazepam 10 Mg Tablet VALIUM diazePAM Oral Tablet diazePAM Oral Solution diazePAM Oral Concentrate
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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: 20 hours, 51 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Streamlined Silver Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze Tier 4 - Non-Preferred — — ✓ QL
Signature Silver Tier 4 - Non-Preferred — — ✓ QL
Signature Gold Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 20 hours, 51 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 Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + 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 Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat AcuDial Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Diastat Pediatric Rectal 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + 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 Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Valtoco 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 20 hours, 51 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
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 Valtoco 		Tier 3 - Non-Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 20 hours, 51 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 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 Advantage 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Valium 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Care 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Value 2026
via Valtoco 		Tier 4 - Higher Cost Brand — — ✓ QL
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
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 20 hours, 51 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 20 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic ✓ — ✓ 10 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) 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
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Valtoco 		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 Dual Plan (HMO D-SNP) 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
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
NHC Advantage (HMO I-SNP)
via Valtoco 		Tier 1 - Preferred Generic — — ✓ 10 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 10 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 10 per 30 days QL
Wellcare Assist Open (PPO)
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
Wellcare Dual Liberty Open (PPO D-SNP)
via Valtoco 		Tier 3 - Preferred Brand ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — — None
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Wellcare Giveback Open (PPO)
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 Value Plus (HMO)
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
Aetna Medicare Full Dual Care (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
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 Chronic Care Value (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | 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
Wellcare Simple (HMO-POS)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Senior Care (HMO I-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 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
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 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 GIVEBACK 012 NC (HMO)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
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
Aetna Medicare Signature (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 Enhanced (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 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 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
Liberty Medicare Advantage (HMO C-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Valtoco 		Tier 4 - Non-Preferred ✓ — ✓ 10 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Valtoco 		Tier 4 - Non-Preferred — — ✓ 10 per 30 days QL
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
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
UHC Complete Care NC-25 (HMO-POS C-SNP)
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
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
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
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
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 Champion (HMO-POS C-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
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
Alignment Health AVA (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthSpring True Choice (PPO)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HealthSpring TotalCare (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 TotalCare Plus (HMO D-SNP)
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
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
Humana Gold Plus H1036-335 (HMO-POS)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days 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
Humana Gold Plus SNP-DE H1036-331 (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
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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
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
Humana Dual Select H1036-307 (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 Gold Plus SNP-DE H1036-167 (HMO D-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
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Valtoco 		Tier 5 - Specialty ✓ — ✓ 10 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days QL
HumanaChoice H5216-211 (PPO)
via Valtoco 		Tier 5 - Specialty — — ✓ 10 per 30 days 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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 20 hours, 50 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: Oct 1, 2026  ·  Checked: 20 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Libervant 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Libervant 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Libervant 		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 Valtoco 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Valtoco 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 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 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Valium 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 20 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — — None
Secure | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard Tier 3 - Preferred Brand — — — None
Silver Classic Standard Tier 3 - Preferred Brand — — — None
Bronze Classic Standard Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 Tier 3 - Preferred Brand — — — None
Secure Tier 3 - Preferred Brand — — — None
Silver Classic Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — — None
Bronze Classic 4700
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — — None
AIAN Cost Share Tier 3 - Preferred Brand — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — — None
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — — None
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure | with Atrium Health
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 | 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
Gold Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic | 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 Simple PCP Saver | 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
Gold Elite Saver Plus | 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
Silver Simple PCP Saver
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus
via Libervant 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic
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
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 20 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 20 hours, 50 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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 Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, 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 Standard (HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
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