dofetilide
125 mcg, 0.125 mg, 250 mcg, 0.25 mg, 500 mcg, 0.5 mg — Capsule
Also known as:
Tikosyn
dofetilide caps 125mcg, 250mcg, 500mcg
dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg (0.5 mg)
Dofetilide 125 Mcg Capsule
Dofetilide 250 Mcg Capsule
Dofetilide 500 Mcg Capsule
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
4 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Tikosyn |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Local 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Value 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Care 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Cigna
1 planMedicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Select (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Plus (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health Platinum (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
NC Medicaid PDL
2 plansNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 4 - Specialty Generic | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 4 - Specialty Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 4 - Specialty Generic | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Tikosyn |
Tier 6 - Non-Preferred Brand Specialty | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Tikosyn |
Tier 6 - Non-Preferred Brand Specialty | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via Tikosyn |
Tier 6 - Non-Preferred Brand Specialty | — | — | — | None |