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
Dofetilide Oral 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 |
|---|---|---|---|---|---|
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold | 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 Silver | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | 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 Basic Option 2026 | Tier 4 - Preferred Specialty | — | — | — | None |
| BCBS Federal Standard 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 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 |
|
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 Local 2026
via Tikosyn |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Gold 1500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect myDiabetesCare Silver | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver RD CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Bronze CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 4 - Non-Preferred | — | — | ✓ | QL |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (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 |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| 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 |
| AARP Medicare Advantage from UHC NC-0015 (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 |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | 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 |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-28 (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 |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | 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 |
| Erickson Advantage Freedom (HMO-POS) | 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 |
| 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 |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| 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 |
| 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 |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | 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 |
| HealthSpring Preferred Plus (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Select (HMO) | 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 TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | 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 Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-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 |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | 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 |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Blue Medicare Essential Plus (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 |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | 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 |
| DEVOTED CORE 001 NC (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | 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 GIVEBACK 012 NC (HMO) | 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 |
| 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 |
| 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 |
| 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 |
| Alignment Health AVA (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | 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 |
| 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 |
NC Medicaid PDL
2 plansNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 4 - Specialty Generic | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 4 - Specialty Generic | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Tier 4 - Specialty Generic | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Tikosyn |
Tier 6 - Non-Preferred Brand Specialty | — | — | — | None |
|
NC State Health Plan - 80/20 Plus 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 |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Secure | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
UnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0030042 | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060008 | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060009 | Tier 4 - Non-Preferred | — | — | — | None |
| 54332NC0060010 | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |