Edarbyclor

Generic: azilsartan medoxomil

40 MG — Tablet

Angiotensin Ii Receptor Blocker Diuretic Combinations

Also known as: azilsartan medoxomil EDARBYCLOR TAB 40-12.5 EDARBYCLOR TAB 40-25MG

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

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 11 hours, 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Gold via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Everyday Bronze + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Elite Bronze + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Complete Gold via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Expanded Bronze + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Silver + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Gold + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Silver with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Gold with Atrium Health + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Everyday Bronze via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Elite Bronze via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Clear Silver with $0 Insulin Options via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Expanded Bronze via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Silver via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Everyday Bronze with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Elite Bronze with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Focused Silver with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Complete Gold with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Expanded Bronze with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Silver with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Standard Gold with Atrium Health via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Complete Gold + Vision + Adult Dental via Edarbi	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL

Blue Cross Blue Shield Federal

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 11 hours, 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Edarbi	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	—	—	—	None

Medicare Part D

164 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 11 hours, 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP) via Edarbi	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring True Choice (PPO) via Edarbi	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Edarbi	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Edarbi	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) via Edarbi	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Edarbi	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Edarbi	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Edarbi	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
Wellcare Assist Open (PPO) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple Open (PPO) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Assist Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple (HMO-POS) via Edarbi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Value Plus (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED CORE 001 NC (HMO) via Edarbi	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED GIVEBACK 002 NC (HMO) via Edarbi	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED GIVEBACK 012 NC (HMO) via Edarbi	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	—	✓	✓ 30 per 30 days	ST \| QL
Blue Medicare PPO Enhanced (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Enhanced (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Choice (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Experience Health Medicare Advantage (HMO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare PPO Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Enhanced (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Choice (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Experience Health Medicare Advantage (HMO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Plan I (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Edarbi	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
Healthy Blue + Medicare (HMO-POS D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Signature (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Freedom (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Signature (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Freedom (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Liberty (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Edarbi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Edarbi	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 6 - Specialty Plus	—	—	—	None

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 11 hours, 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Edarbi	Non-Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 11 hours, 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Edarbi	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Edarbi	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Edarbi	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026	Not Covered	—	—	—	None