divalproex sodium
125 mg, 250 mg, 500 mg — Extended Release Tablet
Also known as:
divalproex sodium oral
divalproex sodium cap delayed release sprinkle 125 mg
divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg
divalproex sodium tab er 24 hr 250 mg, 500 mg
DEPAKOTE ER
DIVALPROEX SODIUM ER
DEPAKOTE SPRINKLE
Divalproex Sodium ER Oral Tablet Extended Release
Divalproex Sodium Oral Capsule Delayed Release Sprinkle
Divalproex Sodium Oral Tablet Delayed Release
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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.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield of NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Care 2026
via Depakote Sprinkles |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Depakote Sprinkles |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Depakote Sprinkles |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Value 2026
via Depakote Er |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Care 2026
via Depakote Er |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Local 2026
via Depakote Er |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Depakote Er |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Depakote Er |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Value 2026
via Depakote Sprinkles |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Local 2026
via Depakote Sprinkles |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (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 Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | 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 |
| 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 |
| 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 Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| HealthSpring True Choice (PPO) | 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 |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | 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 |
| Alignment Health Platinum (HMO) | 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) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | 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) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AIAN Cost Share | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| AIAN Cost Share | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
TRICARE
1 planUnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Gold Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |