Divigel

Generic: estradiol

0.25/0.25G, 0.5MG/0.5G, 0.75/0.75G, 1 MG/GRAM, 1.25/1.25G — GEL IN PACKET (GRAM)

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

340 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Complete Gold + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Silver with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Silver with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Gold + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Silver + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Elite Bronze + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Complete Gold + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Gold with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Silver with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Gold via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Silver via Dotti	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze via Dotti	Tier 2 - Generic	—	—	✓	QL
Clear Silver with $0 Insulin Options via Dotti	Tier 2 - Generic	—	—	✓	QL
Elite Bronze via Dotti	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze via Dotti	Tier 2 - Generic	—	—	✓	QL
Streamlined Silver via Dotti	Tier 2 - Generic	—	—	✓	QL
Streamlined Silver with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Enhanced CHF Heart Care Silver $0 Rx Options via Dotti	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via Dotti	Tier 2 - Generic	—	—	✓	QL
Complete Gold via Dotti	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Gold via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Silver via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via Yuvafem	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Yuvafem	Tier 2 - Generic	—	—	—	None
Elite Bronze via Yuvafem	Tier 2 - Generic	—	—	—	None
Everyday Bronze via Yuvafem	Tier 2 - Generic	—	—	—	None
Streamlined Silver via Yuvafem	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Yuvafem	Tier 2 - Generic	—	—	—	None
Complete Gold via Yuvafem	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Signature Gold via estradiol	Tier 2 - Generic	—	—	—	None
Signature Silver via estradiol	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via estradiol	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via estradiol	Tier 2 - Generic	—	—	—	None
Elite Bronze via estradiol	Tier 2 - Generic	—	—	—	None
Everyday Bronze via estradiol	Tier 2 - Generic	—	—	—	None
Streamlined Silver via estradiol	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via estradiol	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via estradiol	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via estradiol	Tier 2 - Generic	—	—	—	None
Complete Gold via estradiol	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via estradiol	Tier 2 - Generic	—	—	—	None
Elite Bronze via Lyllana	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze via Lyllana	Tier 2 - Generic	—	—	✓	QL
Streamlined Silver via Lyllana	Tier 2 - Generic	—	—	✓	QL
Streamlined Silver with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Enhanced CHF Heart Care Silver $0 Rx Options via Lyllana	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via Lyllana	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health via Dotti	Tier 2 - Generic	—	—	✓	QL
Clear Silver with $0 Insulin Options via Lyllana	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Complete Gold via Lyllana	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Silver via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Silver with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Silver + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Expanded Bronze + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Elite Bronze + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Signature Gold + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Lyllana	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via Yuvafem	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Yuvafem	Tier 2 - Generic	—	—	—	None
Elite Bronze via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Menostar	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Streamlined Silver with Atrium Health via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Complete Gold + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Expanded Bronze with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Focused Silver with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Elite Bronze with Atrium Health via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Gold via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Signature Silver via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
Clear Silver with $0 Insulin Options via Bijuva	Tier 4 - Non-Preferred	—	—	—	None

AmeriHealth Caritas NC

44 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	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 estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	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 estradiol	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 estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via estradiol	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Combipatch	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Bijuva	Tier 4 - Non-Preferred	—	—	✓	QL

Blue Cross Blue Shield Federal

19 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via estradiol	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via Yuvafem	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Yuvafem	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via estradiol	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Yuvafem	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via estradiol	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Evamist	Tier 2 - Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Evamist	Tier 2 - Preferred Brand	—	—	—	None
BCBS Federal Focus 2026 via Evamist	Tier 2 - Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Elestrin	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Myfembree	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026 via Bijuva	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Vagifem	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Estrogel	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Elestrin	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Myfembree	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026 via Bijuva	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Vagifem	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Estrogel	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

35 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Value 2026 via Vagifem	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Vagifem	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Vagifem	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Climara	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Climara	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Climara	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Climara	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Estrace	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Estrace	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Estrace	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Estrace	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Estrace	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Vagifem	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Vagifem	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Climara	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Climara Pro	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Climara Pro	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Climara Pro	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Value 2026 via Climara Pro	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Care 2026 via Climara Pro	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Myfembree	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Myfembree	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Local 2026 via Myfembree	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Care 2026 via Myfembree	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Value 2026 via Myfembree	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Value 2026 via Combipatch	Tier 4 - Higher Cost Brand	—	—	— Restricted Access	None
BCBSNC Blue Care 2026 via Combipatch	Tier 4 - Higher Cost Brand	—	—	— Restricted Access	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Combipatch	Tier 4 - Higher Cost Brand	—	—	— Restricted Access	None
BCBSNC Blue Local 2026 via Combipatch	Tier 4 - Higher Cost Brand	—	—	— Restricted Access	None
BCBSNC Blue Advantage 2026 via Bijuva	Tier 4 - Higher Cost Brand	—	—	—	None
BCBSNC Blue Local 2026 via Bijuva	Tier 4 - Higher Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Bijuva	Tier 4 - Higher Cost Brand	—	—	—	None
BCBSNC Blue Care 2026 via Bijuva	Tier 4 - Higher Cost Brand	—	—	—	None
BCBSNC Blue Value 2026 via Bijuva	Tier 4 - Higher Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Combipatch	Tier 4 - Higher Cost Brand	—	—	— Restricted Access	None

Cigna

80 plans

Source: PDF · Formulary date: Oct 15, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3600 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Silver via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver 5000 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 2200 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 6500 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Bronze via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3000 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Bronze via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3600 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Silver via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver 5000 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3600 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Gold RD CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Gold CMS Standard via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Gold RD CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Gold CMS Standard via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver 5000 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible via estradiol	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 2200 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 6500 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD CMS Standard via estradiol	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible via Lyllana	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Silver via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Bronze via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3000 Indiv Med Deductible via Dotti	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver 3000 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold RD CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver 5000 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD CMS Standard via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect myDiabetesCare Silver via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect myDiabetesCare Bronze via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 6500 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 2200 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver 3600 Indiv Med Deductible via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL

Medicare Part D

738 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Liberty Medicare Dual Plan (HMO D-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
Liberty Medicare Dual Plan (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring True Choice (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Myfembree	Tier 1 - Preferred Generic	✓	—	—	PA
Longevity Health Plan (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Imvexxy	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
Longevity Health Plan (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Lyllana	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Senior Care (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Plus (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Savings (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred Select (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring Preferred (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Prime (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Troy Medicare (HMO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Climara Pro	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Climara Pro	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Climara Pro	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Lyllana	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Lyllana	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Lyllana	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
PruittHealth Premier (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via estradiol	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Dotti	Tier 1 - Preferred Generic	—	—	✓ 8 per 28 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Liberty Medicare Advantage (HMO C-SNP) via Yuvafem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Senior Care (HMO I-SNP) via Yuvafem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
HealthSpring Preferred Savings (HMO) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Wellcare Giveback Open (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Wellcare Simple (HMO-POS) via Yuvafem	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Yuvafem	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via estradiol	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO) via Dotti	Tier 2 - Generic	—	—	✓ 8 per 28 days	QL
Wellcare Giveback Open (PPO) via Yuvafem	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via estradiol	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via estradiol	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Full Access H5525-034 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5216-211 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
DEVOTED CHOICE 005 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-137 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-026 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Blue Medicare Essential Plus (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Dual Select H5525-072 (PPO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-070 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-050 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-049 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice Giveback H5525-035 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Full Access H5525-034 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5216-211 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-233 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Blue Medicare Choice (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Abigale 1/0.5 28 Day	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
DEVOTED CHOICE 001 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Choice H8145-004 (PFFS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HealthSpring TotalCare Plus (HMO D-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Lyllana	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Lyllana	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-070 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-050 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-049 (PPO) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Dotti	Tier 3 - Preferred Brand	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Simple Open (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Simple (HMO-POS) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Simple Open (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Simple (HMO-POS) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Simple Open (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Simple (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Simple Open (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Simple (HMO-POS) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Giveback Open (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Giveback Open (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Giveback Open (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Giveback Open (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HealthTeam Advantage Plan I (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Troy Medicare (HMO) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Assist Open (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Assist Open (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Abigale 1/0.5 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-233 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice H5216-211 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Full Access H5525-034 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice Giveback H5525-035 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-049 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-050 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-070 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Dual Select H5525-072 (PPO D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
HumanaChoice H5525-083 (PPO) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-026 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Humana Gold Choice H8145-004 (PFFS) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Abigale Lo 0.5/0.1 28 Day	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Giveback (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Extra (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Care (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Prime (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Value Plus (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Dual (HMO D-SNP) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (HMO) via Dotti	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Combipatch	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Yuvafem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Giveback (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Extra (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (PPO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Enhanced (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature Care (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Prime (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Value Plus (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Dual (HMO D-SNP) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Aetna Medicare Signature (HMO) via Lyllana	Tier 4 - Non-Preferred	—	—	✓ 8 per 28 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via estradiol	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
Erickson Advantage Freedom (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
Erickson Advantage Signature (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Yuvafem	Tier 4 - Non-Preferred	—	—	✓ 18 per 28 days	QL
Erickson Advantage Liberty (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Climara Pro	Tier 4 - Non-Preferred	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Myfembree	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Myfembree	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare (HMO) via Myfembree	Tier 5 - Specialty	✓	—	—	PA

NC Medicaid PDL

13 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Climara Pro	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Evamist	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Myfembree	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Combipatch	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Estrace	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Lyllana	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via estradiol gel packet	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Menostar	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Bijuva	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Climara	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via estradiol	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Dotti	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Elestrin	Non-Preferred	—	—	—	None

NC State Health Plan

18 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via estradiol	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Yuvafem	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Myfembree	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026 via Myfembree	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via Myfembree	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via Estrogel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Estrogel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Bijuva	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Bijuva	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Bijuva	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Estrogel	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Vagifem	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Vagifem	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Vagifem	Not Covered	—	—	—	None

Oscar Health

378 plans

Source: CMS QHP JSON · Formulary date: Oct 13, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
69803NC0010083 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010076 via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010075 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010074 via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Classic \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010112 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010113 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010114 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010115 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010116 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010117 via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010077 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010078 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010079 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010080 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010081 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010082 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010083 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010084 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010085 via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Core Plan via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Core Plan \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010108 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010109 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010110 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010111 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010112 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010113 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010114 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010115 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010116 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010117 via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Gold Classic Standard via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Classic Standard via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Classic Standard via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010075 via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010074 via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010081 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010080 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010079 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010078 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010077 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010111 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010110 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010109 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010108 via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Core Plan \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Core Plan via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Diabetes via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010085 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010084 via estradiol	Tier 2 - Generic	—	—	✓	QL
69803NC0010082 via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Secure \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple PCP Saver via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Classic 4700 via estradiol	Tier 2 - Generic	—	—	✓	QL
Secure via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus via estradiol	Tier 2 - Generic	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via estradiol	Tier 2 - Generic	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic via Yuvafem	Tier 2 - Generic	—	—	—	None
Secure via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Yuvafem	Tier 2 - Generic	—	—	—	None
69803NC0010076 via Yuvafem	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010112 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010111 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010110 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010109 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010108 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Core Plan \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Core Plan via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010077 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010076 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010075 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010074 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Secure \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010085 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010084 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010083 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010079 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple PCP Saver via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic 4700 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Secure via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010080 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Gold Classic Standard via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Classic Standard via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Classic Standard via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010078 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010081 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010082 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010117 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010116 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010115 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010114 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
69803NC0010113 via Climara Pro	Tier 3 - Preferred Brand	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010081 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010082 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010083 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010084 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010085 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Core Plan via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Core Plan \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010108 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010109 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010110 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010111 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010112 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010113 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010114 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010115 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010116 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010117 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic Standard via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic Standard via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Gold Classic Standard via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Secure via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic 4700 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Secure \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010074 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010075 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010076 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010077 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010078 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010079 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010080 via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010115 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010116 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010117 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic Standard via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Secure via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Secure \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010074 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010075 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010076 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010077 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010078 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010079 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010080 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010081 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010082 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010083 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010084 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010085 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Core Plan via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Core Plan \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010108 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010109 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010110 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010111 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010112 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010113 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010114 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010115 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010116 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010117 via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Elestrin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Secure via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Secure \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010074 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010075 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010076 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010077 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010078 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010079 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010080 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010081 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010082 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010083 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010084 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010085 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Core Plan via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Core Plan \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010108 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010109 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010110 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010111 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010112 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010113 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010114 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010115 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010116 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
69803NC0010117 via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes with Adult Dental & Vision \| with Atrium Health via Evamist	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple PCP Saver via Imvexxy	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic Standard via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic Standard via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Gold Classic Standard via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic Standard \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic Standard \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Gold Classic Standard \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Secure via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic 4700 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple PCP Saver via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Secure \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Classic 4700 \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Classic \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple PCP Saver \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010074 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010075 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010076 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010077 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010078 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010079 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010080 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010081 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010082 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010083 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010084 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010085 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Bronze Simple Diabetes via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Core Plan via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Core Plan \| with Atrium Health via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
Silver Simple Diabetes with Adult Dental & Vision via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010108 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010109 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010110 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010111 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010112 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010113 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL
69803NC0010114 via Estrogel	Tier 4 - Non-Preferred	—	—	✓	QL

TRICARE

12 plans

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via Yuvafem	Tier 1 - Generic Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Lyllana	Tier 1 - Generic Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Dotti	Tier 1 - Generic Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via estradiol	Tier 1 - Generic Formulary (Basic Core)	✓	—	✓ 1270/48001/87580 DOD SINGLE DOSE MEDS >30 DAYS: QUANTITY DQL	PA \| QL PA on 223 of 237 NDCs: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH; Quantity limit on 3 of 237 NDCs
TRICARE Uniform Formulary 2026 via Estrace	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Estrogel	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Vagifem	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Menostar	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Myfembree	Tier 2 - Brand Formulary	✓	—	—	PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026 via Elestrin	Tier 2 - Brand Formulary	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH
TRICARE Uniform Formulary 2026 via Climara	Tier 2 - Brand Formulary (Basic Core)	✓	—	—	PA PA: TPA - ESTROGENIC AGENTS,VAGINAL ESTROGEN PREPARATIONS FOR MALE PATIENTS REQ PRIOR AUTH

UnitedHealthcare

102 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 7 hours, 12 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Yuvafem	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 Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Lyllana	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Yuvafem	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via estradiol	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Dotti	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Climara Pro	Tier 4 - Non-Preferred	—	—	✓	QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Bijuva	Tier 4 - Non-Preferred	—	—	—	None