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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Expanded Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Silver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Gold Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Silver with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Gold with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 7 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Troy Medicare (HMO) Tier 2 - Generic ✓ — ✓ 45 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — ✓ 45 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — ✓ 90 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
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