Follistim

Generic: follitropin beta

Also known as: follitropin beta
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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  ·  Checked: 6 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 6 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via Follistim Aq 		Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026
via Follistim Aq 		Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026
via Follistim Aq 		Tier 4 - Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Jun 1, 2026  ·  Checked: 6 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Follistim Aq 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Value 2026
via Follistim Aq 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Care 2026
via Follistim Aq 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Local 2026
via Follistim Aq 		Tier 4 - Higher Cost Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via Follistim Aq 		Tier 4 - Higher Cost Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver 3500 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Silver
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze RD 5000 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver 4400 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect myDiabetesCare Bronze
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver 3000 Indiv Med Deductible
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver RD CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Gold RD CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Silver CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Gold CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze RD CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Connect Bronze CMS Standard
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 6 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Follistim Aq 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via Follistim Aq 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via Follistim Aq 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 36 minutes ago
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 Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard (No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Gold Standard (No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 5 - Specialty ✓ — — PA
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Gold Standard (No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Silver Standard (No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — — PA
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Follistim Aq 		Tier 5 - Specialty ✓ — — PA
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 5 - Specialty ✓ — — PA
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