Fetzima

Generic: levomilnacipran

20-40 Mg — Extended Release Capsule

GENITOURINARY AGENTS - MISC.

Also known as: FETZIMA CAP TITRATIO levomilnacipran Fetzima 20-40 Mg Titration Pack Fetzima Er 20 Mg Capsule Fetzima Er 40 Mg Capsule Fetzima Er 80 Mg Capsule Fetzima Er 120 Mg Capsule Fetzima Oral Capsule 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.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze Tier 4 - Non-Preferred ✓ — — PA
Signature Silver Tier 4 - Non-Preferred ✓ — — PA
Signature Gold Tier 4 - Non-Preferred ✓ — — PA
Complete Gold Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — ✓ Restricted Access QL
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — ✓ Restricted Access QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — ✓ Restricted Access QL
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — ✓ Restricted Access QL
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — ✓ Restricted Access QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Gold CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze CMS Standard Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver 3600 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Connect Silver 5000 Indiv Med Deductible Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 30 per 30 days ST | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 30 per 30 days ST | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 30 per 30 days ST | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple (HMO-POS) 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 Giveback Open (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
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 Assist Open (PPO) 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
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Troy Medicare (HMO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — ✓ ✓ 30 per 30 days ST | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | 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
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Senior Care (HMO I-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 8 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
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