icatibant
Generic: Sajazir
30 MG/3 ML — Prefilled Syringe
Hereditary Angioedema (Hae) Treatment Agents
Also known as:
Firazyr
Icatibant 30 Mg/3 Ml Syringe
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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 |
|---|---|---|---|---|---|
|
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 | 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 |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | 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 |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold 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 |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Standard Gold + Vision + Adult Dental
via Sajazir |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold 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 Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold + Vision + Adult Dental | 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 |
AmeriHealth Caritas NC
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AmeriHealth Caritas Next Silver Essential + No Referrals
via Sajazir |
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 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 |
|
AmeriHealth Caritas Next Gold Premier + 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
via Firazyr |
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 Care 2026
via Firazyr |
Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
|
BCBSNC Blue Advantage 2026
via Firazyr |
Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
|
BCBSNC Blue Value 2026
via Firazyr |
Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Firazyr |
Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
|
BCBSNC Blue Local 2026
via Firazyr |
Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
Cigna
40 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Connect Bronze 6500 Indiv Med Deductible
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 Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Bronze CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Connect Gold RD CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 3500 Indiv Med Deductible | 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 Silver CMS Standard
via Sajazir |
Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 4400 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | ✓ | — | — | PA |
| Connect Bronze CMS Standard | 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 |
Medicare Part D
224 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Longevity Health Plan (HMO I-SNP)
via Sajazir |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | 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) | 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 | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 18 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) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 36 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | 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) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 27 per 30 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | 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 |
|
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) | 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) | Tier 5 - Specialty | ✓ | — | ✓ 27 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 | Preferred | ✓ | — | — | PA |
|
NC Medicaid Preferred Drug List 2026
via Sajazir |
Preferred | ✓ | — | — | PA |
|
NC Medicaid Preferred Drug List 2026
via Firazyr |
Non-Preferred | ✓ | — | — | PA |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - HDHP 2026
via sajazir sosy |
Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - 80/20 Plus PPO 2026
via sajazir sosy |
Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - 70/30 Standard PPO 2026
via sajazir sosy |
Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AIAN Cost Share | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |