Euflexxa

Generic: sodium hyaluronate

20 MG — Prefilled Syringe

Also known as: sodium hyaluronate Sodium Hyaluronate Euflexxa Intra-articular Solution Prefilled Syringe
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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: 17 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Silver
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Gold
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Silver + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Complete Gold
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Gold + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options
via Provisc 		Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 17 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 17 hours, 38 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010074
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010075
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010076
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010077
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010078
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010079
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010080
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010081
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010082
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010083
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010084
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010085
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010108
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010109
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010110
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010111
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010112
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010113
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010114
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010115
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010116
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010117
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010074
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010075
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010076
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010077
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010078
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010079
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010080
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010081
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010082
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010083
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010084
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010085
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010108
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010109
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010110
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010111
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010112
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010113
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010114
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010115
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010116
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010117
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Monovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Tier 5 - Specialty ✓ — ✓ PA | QL
Secure Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010074 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010075 Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010076 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010077 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010078 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010079 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010080 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010081 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010082 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010083 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010084 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010085 Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Core Plan | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010108 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010109 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010110 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010111 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010112 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010113 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010114 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010115 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010116 Tier 5 - Specialty ✓ — ✓ PA | QL
69803NC0010117 Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Orthovisc 		Tier 5 - Specialty ✓ — ✓ PA | QL
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