Diltiazem

120 Mg — Tablet

Calcium Channel Blocker

Also known as: Diltiazem 120 Mg Tablet Diltiazem 12Hr Er 60 Mg Capsule Diltiazem 12Hr Er 90 Mg Capsule Diltiazem 12Hr Er 120 Mg Capsule Diltiazem 24Hr Er 120 Mg Capsule Diltiazem 24Hr Er 180 Mg Capsule Diltiazem 24Hr Er 240 Mg Capsule Diltiazem 24Hr Er 300 Mg Capsule Diltiazem 24Hr Er 360 Mg Capsule Diltiazem 24Hr Er 420 Mg Capsule Diltiazem 30 Mg Tablet Diltiazem 60 Mg Tablet Diltiazem 90 Mg Tablet
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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: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Silver
via Tiadylt 		Tier 2 - Generic — — — None
Standard Gold
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Complete Gold
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Tiadylt 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Everyday Bronze
via Tiadylt 		Tier 2 - Generic — — — None
Elite Bronze
via Tiadylt 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Tiadylt 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Gold
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Silver
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Elite Bronze
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Everyday Bronze
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via Tiadylt 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Matzim La 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Matzim La 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Matzim La 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Tiadylt 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Tiadylt 		Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Tiadylt 		Tier 1 - Generic — — — None
Cigna Plus NC 4-Tier Formulary 2026
via Matzim La 		Tier 2 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Aetna Medicare Chronic Care (HMO C-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring Preferred (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring Preferred (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
DEVOTED CHOICE 001 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Blue Medicare Choice (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Blue Medicare Essential (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare Choice (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare Essential (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Alignment Health Platinum (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan I (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Assist Open (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Tiadylt 		Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via diltiazem hydrochloride 		Tier 6 - Specialty Plus — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Tiadylt 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Matzim La 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 8 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 22 hours, 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Matzim La 		Tier 3 - Mid-Range Cost — — — None
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