Firazyr
Generic: icatibant
30MG/3ML — Prefilled Syringe
Hereditary Angioedema (Hae) Treatment Agents
Also known as:
FIRAZYR SOSY 30MG/3ML
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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)
58 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Standard Silver with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Clear Silver with $0 Insulin Options
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Clear Silver with $0 Insulin Options
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Everyday Bronze with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Elite Bronze with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold with Atrium Health
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AmeriHealth Caritas Next Gold Premier + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Premier + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Premier + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + No Referrals
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBS Federal Standard Option 2026
via Sajazir |
Tier 4 - Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Basic Option 2026
via Sajazir |
Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Local 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Value 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Advantage 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Care 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
Cigna
40 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Connect Gold CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 6500 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 3000 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 5000 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 4400 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 3500 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect myDiabetesCare Silver
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 2200 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold 1500 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect myDiabetesCare Bronze
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 5500 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD 6000 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 3500 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD 5000 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 3500 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 4400 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 5000 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 3000 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 6500 Indiv Med Deductible
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold RD CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect myDiabetesCare Bronze
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze 5500 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD 6000 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver 3500 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze RD 5000 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect myDiabetesCare Silver
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Silver RD 2200 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold 1500 Indiv Med Deductible
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold RD CMS Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
Medicare Part D
224 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
NHC Advantage (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Liberty Medicare Dual Plan (HMO D-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
PruittHealth Premier (HMO I-SNP)
via icatibant |
Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Sajazir |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Blue Medicare Choice (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Essential (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Experience Health Medicare Advantage (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Platinum (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health smartHMO (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Platinum Select (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health AVA (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Platinum (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health smartHMO (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Platinum Select (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Alignment Health AVA (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthTeam Advantage Plan I (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Plan II (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Vitality Plan (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Troy Medicare (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Assist Open (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Dual Access (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Humana Gold Plus H1036-137 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H1036-233 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H1036-335 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice Giveback H5216-017 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5216-211 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Full Access H5525-034 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice Giveback H5525-035 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-049 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-050 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-070 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-083 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-025 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-026 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-057 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-061 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Choice H8145-004 (PFFS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H1036-137 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H1036-233 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H1036-335 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice Giveback H5216-017 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5216-211 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Full Access H5525-034 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice Giveback H5525-035 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-049 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-050 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-070 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HumanaChoice H5525-083 (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-025 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-026 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-057 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus H6622-061 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Choice H8145-004 (PFFS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Senior Care (HMO I-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Erickson Advantage Signature (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Erickson Advantage Freedom (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Erickson Advantage Liberty (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
|
Aetna Medicare Signature (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Dual (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Value Plus (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Prime (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Care (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Extra (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Giveback (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Dual (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Value Plus (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Prime (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Care (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Extra (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature Giveback (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
HealthSpring True Choice (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring True Choice (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Select (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Savings (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Plus (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Select (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Savings (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
HealthSpring Preferred Plus (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CORE 001 NC (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CORE 001 NC (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Liberty Medicare Advantage (HMO C-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Simple Open (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Simple (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Wellcare Giveback Open (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Enhanced (HMO-POS)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Choice (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Essential (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Experience Health Medicare Advantage (HMO)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
|
Blue Medicare Enhanced (HMO-POS)
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
NC Medicaid PDL
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC Medicaid Preferred Drug List 2026
via icatibant |
Preferred | ✓ | — | — | PA |
|
NC Medicaid Preferred Drug List 2026
via Sajazir |
Preferred | ✓ | — | — | PA |
| NC Medicaid Preferred Drug List 2026 | Non-Preferred | ✓ | — | — | PA |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Bronze Elite + PCP Saver Plus
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AIAN Cost Share | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AIAN Cost Share
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via icatibant |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard (No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Standard (No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Gold Standard (No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard+ Dental + Vision (No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via icatibant |
Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |