Hyqvia 30 G / 300 ML Kit

Generic: hyaluronidase, human recombinant

100 MG — Kit

Also known as: Hyqvia Subcutaneous Kit

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

116 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 12 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Complete Gold	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Complete Gold + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Standard Silver + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Standard Gold + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Clear Silver with $0 Insulin Options via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Clear Silver with $0 Insulin Options via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Clear Silver with $0 Insulin Options via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	—	PA
Complete Gold via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Clear Silver with $0 Insulin Options	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze	Tier 5 - Specialty	✓	—	—	PA
Standard Silver	Tier 5 - Specialty	✓	—	—	PA
Standard Gold	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Focused Silver with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Silver with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Standard Gold with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA

AmeriHealth Caritas NC

40 plans

Source: CMS QHP JSON · Checked: 12 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA

Oscar Health

112 plans

Source: CMS QHP JSON · Checked: 12 hours, 51 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Simple Diabetes via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Chronic Care CKM \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Diabetes \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Chronic Care CKM \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Chronic Care CKM \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Diabetes \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Chronic Care CKM \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share \| with Atrium Health via Hyqvia 5 G / 50 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Chronic Care CKM \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Diabetes \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Chronic Care CKM \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share \| with Atrium Health via Hyqvia 20 G / 200 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus	Tier 5 - Specialty	✓	—	—	PA
Silver Classic	Tier 5 - Specialty	✓	—	—	PA
Secure	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes	Tier 5 - Specialty	✓	—	—	PA
Secure \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Classic \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Diabetes \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Simple Diabetes \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share	Tier 5 - Specialty	✓	—	—	PA
AIAN Cost Share \| with Atrium Health	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic Standard \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic Standard \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Classic Standard \| with Atrium Health via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Elite + PCP Saver Plus via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Classic via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Secure via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Bronze Classic 4700 via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Silver Simple PCP Saver via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA
Gold Elite Saver Plus via Hyqvia 2.5 G / 25 ML Kit	Tier 5 - Specialty	✓	—	—	PA