Ibrance
Generic: palbociclib
75MG, 100MG, 125MG — Capsule
ANTINEOPLASTIC ENZYME INHIBITORS
Also known as:
IBRANCE CAPS 75MG, 100MG, 125MG; TABS 75MG, 100MG, 125MG
palbociclib
Ibrance 75 Mg Capsule
Ibrance 100 Mg Capsule
Ibrance 125 Mg Capsule
Ibrance 75 Mg Tablet
Ibrance 100 Mg Tablet
Ibrance 125 Mg Tablet
IBRANCE CAPS 75MG, 100MG, 125MG; TABS
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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)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
Cigna
1 planMedicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 21 per 28 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 21 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 21 per 28 days | PA | QL |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |