etodolac

400 mg, 500 mg, 600 mg — Capsule

Also known as: etodolac caps 200mg, 300mg; tabs 400mg, 500mg; tb24 400mg, 500mg, 600mg etodolac cap 200 mg, 300 mg etodolac tab er 24hr 400 mg, 500 mg, 600 mg etodolac tab 400 mg etodolac tab 500 mg Etodolac 200 Mg Capsule Etodolac 300 Mg Capsule Etodolac 400 Mg Tablet Etodolac 500 Mg Tablet Etodolac Er 400 Mg Tablet Etodolac Er 500 Mg Tablet Etodolac Er 600 Mg Tablet etodolac caps 200mg, 300mg; tabs 400mg, Etodolac Oral Capsule Etodolac Oral Tablet Etodolac ER Oral Tablet Extended Release

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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

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Expanded Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 2 - Generic	—	—	—	None
Everyday Bronze	Tier 2 - Generic	—	—	—	None
Elite Bronze	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze	Tier 2 - Generic	—	—	—	None
Standard Silver	Tier 2 - Generic	—	—	—	None
Standard Gold	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Silver + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Complete Gold	Tier 2 - Generic	—	—	—	None

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + 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 Silver Off-Marketplace High + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 2 - Generic	—	—	—	None

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Aug 7, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	—	None

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Aug 1, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 via Lodine	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Lodine	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Lodine	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Lodine	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Lodine	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

20 plans

Source: PDF · Formulary date: Aug 21, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 5000 Indiv Med Deductible	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 4400 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver 3500 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 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

Medicare Part D

137 plans

Source: CMS QHP JSON · Formulary date: Aug 19, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 90 per 30 days	QL
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 90 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 90 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	✓ 90 per 30 days	QL
Alignment Health smartHMO (HMO)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum Select (HMO)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare (HMO)	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP)	Tier 2 - Generic	—	—	✓ 90 per 30 days	QL
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	✓ 90 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 001 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 003 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 005 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE 008 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	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
HealthSpring True Choice (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	—	—	✓ 30 per 30 days	QL
HealthSpring TotalCare (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO)	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
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
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
AARP Medicare Advantage from UHC NC-0021 (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-0007 (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-0008 (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-0011 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (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 Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (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-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (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-26 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
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
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
Wellcare Assist Open (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	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
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	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
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
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 Chronic Care (HMO C-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 Chronic Care Value (HMO C-SNP)	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

NC State Health Plan

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 1 - Preferred Generic	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
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
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
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 Diabetes \| 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 Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus	Tier 2 - Generic	—	—	—	None
Silver Classic	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

UnitedHealthcare

17 plans

Source: PDF · Formulary date: Aug 25, 2026 · Checked: 3 hours, 56 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard+ Dental + Vision (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, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None
54332NC0030042	Tier 3 - Preferred Brand	—	—	—	None
54332NC0060008	Tier 3 - Preferred Brand	—	—	—	None
54332NC0060009	Tier 3 - Preferred Brand	—	—	—	None
54332NC0060010	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	—	—	—	None