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: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		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 Tiadylt 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Expanded Bronze + 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
Focused Silver with Atrium Health + 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
Elite Bronze + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Tiadylt 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via diltiazem hydrochloride 		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
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
Complete Gold with Atrium Health + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold
via Tiadylt 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Tiadylt 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
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
Streamlined Silver
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Streamlined Silver
via diltiazem hydrochloride 		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
Everyday Bronze with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Gold
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Signature Silver
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Everyday Bronze
via Tiadylt 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via Tiadylt 		Tier 2 - Generic — — — None
Signature Silver
via Tiadylt 		Tier 2 - Generic — — — None
Signature Gold
via Tiadylt 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Tiadylt 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via Matzim La 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Tiadylt 		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
BCBS Federal Standard Option 2026
via Matzim La 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Matzim La 		Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver 5000 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver 3600 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard
via Matzim La 		Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible
via Matzim La 		Tier 3 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Matzim La 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Matzim La 		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 Community 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) 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
Longevity Health Plan (HMO I-SNP)
via diltiazem hydrochloride 		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 Advantage Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (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) 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
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) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) 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 Matzim La 		Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via diltiazem hydrochloride 		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) Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 1 - Preferred 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 (HMO) Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO) Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO) Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO) 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
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
Aetna Medicare Signature Giveback (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via Matzim La 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
HealthSpring True Choice (PPO) Tier 2 - Generic — — — None
HealthSpring True Choice (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Matzim La 		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) Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP) 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 Matzim La 		Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO)
via Matzim La 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via Matzim La 		Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO)
via Matzim La 		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) Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO) Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO) Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO) 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 C-SNP PREMIUM 014 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 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 DUAL FULL 013 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 2 - Generic — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) 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 DUAL PLUS 006 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) 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 CORE 001 NC (HMO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO) 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
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) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
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) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via Matzim La 		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) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) 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 Matzim La 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
Blue Medicare Choice (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Blue Medicare Essential (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Matzim La 		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) Tier 2 - Generic — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 2 - Generic — — — None
Blue Medicare Enhanced (HMO-POS) Tier 2 - Generic — — — None
Blue Medicare Choice (HMO) Tier 2 - Generic — — — None
Blue Medicare Essential (HMO) Tier 2 - Generic — — — None
Experience Health Medicare Advantage (HMO) Tier 2 - Generic — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) 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
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health AVA (PPO) 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
HealthTeam Advantage Plan I (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Plan II (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Vitality Plan (PPO) 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
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) 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
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Assist Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) 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 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
HumanaChoice H5525-049 (PPO)
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) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 2 - Generic — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5216-211 (PPO) Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO) Tier 2 - Generic — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 2 - Generic — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-049 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-050 (PPO) Tier 2 - Generic — — — None
HumanaChoice H5525-070 (PPO) Tier 2 - Generic — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 2 - Generic — — — None
HumanaChoice H5525-083 (PPO) Tier 2 - Generic — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 2 - Generic — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 2 - Generic — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 2 - Generic — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Matzim La 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Matzim La 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via Matzim La 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via Matzim La 		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 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
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Signature (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS) 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 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
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Matzim La 		Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Matzim La 		Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Matzim La 		Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Matzim La 		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) Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) 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 Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Matzim La 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Matzim La 		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
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
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) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Tiadylt 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (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 smartHMO (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-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
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Matzim La 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Matzim La 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Matzim La 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Matzim La 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Matzim La 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Matzim La 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via Matzim La 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Matzim La 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via diltiazem hydrochloride 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Matzim La 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Matzim La 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Matzim La 		Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO)
via Matzim La 		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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Matzim La 		Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via diltiazem hydrochloride 		Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Tiadylt 		Tier 6 - Specialty Plus — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 2 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: Oct 1, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Tiadylt 		Tier 1 - Preferred Generic — — — None
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
Source: CMS QHP JSON  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic 4700 | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AIAN Cost Share
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple Diabetes | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Classic | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Secure | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple Diabetes
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Gold Elite Saver Plus
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Simple PCP Saver
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Classic 4700
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Secure
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Classic
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Bronze Elite + PCP Saver Plus
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
AIAN Cost Share | with Atrium Health
via diltiazem hydrochloride 		Tier 1 - Preferred Generic — — — None
Silver Classic Standard
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Gold Classic Standard
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Bronze Classic Standard
via diltiazem hydrochloride 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 15 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Tiadylt 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via diltiazem hydrochloride 		Tier 3 - Preferred Brand — — — None
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