erythromycin

Generic: Ery

250 mg, 333 mg, 500 mg — Tablet

CEPHALOSPORINS

Also known as: erythromycin oral Ilotycin Emcin, Erycette, EryGel, et. al. Emcin, EryDerm, EryMax, et. al erythromycin tab delayed release 250 mg, 333 mg, 500 mg erythromycin tab 250 mg, 500 mg erythromycin soln 2% Erythromycin 200 Mg/5 Ml Oral Suspension Erythromycin 400 Mg/5 Ml Oral Suspension Erythromycin 250 Mg Tablet Erythromycin 500 Mg Tablet Erythromycin Dr 250 Mg 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.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Signature Gold
via Ery 		Tier 2 - Generic — — — None
Signature Silver
via Ery 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via Ery 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Ery 		Tier 2 - Generic — — — None
Elite Bronze
via Ery 		Tier 2 - Generic — — — None
Everyday Bronze
via Ery 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Ery 		Tier 2 - Generic — — — None
Complete Gold
via Ery 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Streamlined Silver
via Ery-Tab 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Gold
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Silver
via Ery-Tab 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Ery-Tab 		Tier 2 - Generic — — — None
Elite Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Everyday Bronze
via Ery-Tab 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Ery-Tab 		Tier 2 - Generic — — — None
Complete Gold
via Ery-Tab 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Streamlined Silver
via Ery 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Ery 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Ery 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Everyday Bronze Tier 4 - Non-Preferred — — — None
Elite Bronze Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze Tier 4 - Non-Preferred — — — None
Signature Silver Tier 4 - Non-Preferred — — — None
Signature Gold Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Streamlined Silver Tier 4 - Non-Preferred — — — None
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals 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 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 Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals 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 Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Ery 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 5000 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Ery 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Ery 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Ery 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Ery 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (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 Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Ery 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Ery 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Assist Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Care (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Prime (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Extra (PPO)
via Ery 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Dual (HMO D-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature Giveback (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Value Plus (HMO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (PPO)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Ery 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Ery 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Ery 		Tier 2 - Generic — — — None
Aetna Medicare Enhanced (HMO)
via Ery 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Ery 		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
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Ery 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Ery 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Ery 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 005 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
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 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 016 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 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (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 Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO)
via Ery 		Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Ery 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (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 H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) 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
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS) 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
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 GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Ery-Tab 		Non-Preferred — — — None
Source: CMS QHP JSON  ·  Checked: 10 hours, 43 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Gold Elite Saver Plus Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
AIAN Cost Share
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Secure
via Ery 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Ery-Tab 		Tier 2 - Generic — — — None
Gold Classic Standard
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Classic Standard
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Ery-Tab 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Ery-Tab 		Tier 2 - Generic — — — None
Secure
via Ery-Tab 		Tier 2 - Generic — — — None
Silver Classic
via Ery-Tab 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Ery-Tab 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Classic
via Ery 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Gold Classic Standard
via Ery 		Tier 2 - Generic — — — None
Silver Classic Standard
via Ery 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Ery 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Ery 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via Ery 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Ery 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
AIAN Cost Share
via Ery 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via Ery 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Ery 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Ery 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 10 hours, 42 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Ery 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
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