Iclusig

Generic: ponatinib

10MG, 15MG, 30MG, 45MG — Tablet

ANTINEOPLASTICS

Also known as: ICLUSIG TABS 10MG, 15MG, 30MG, 45MG ponatinib Iclusig 10 Mg Tablet Iclusig 15 Mg Tablet Iclusig 30 Mg Tablet Iclusig 45 Mg Tablet ICLUSIG TABS 10MG, 15MG, 30MG Iclusig Oral Tablet
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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  ·  Formulary date: Jan 1, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze 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
Everyday Bronze with Atrium Health + 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
Signature Expanded Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Signature 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
Signature Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Standard Option 2026 Tier 4 - Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026 Tier 5 - Specialty ✓ — ✓ Restricted Access; Limited Distribution PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 5 - Specialty ✓ — ✓ Restricted Access; Limited Distribution PA | QL
BCBSNC Blue Advantage 2026 Tier 5 - Specialty ✓ — ✓ Restricted Access; Limited Distribution PA | QL
BCBSNC Blue Local 2026 Tier 5 - Specialty ✓ — ✓ Restricted Access; Limited Distribution PA | QL
BCBSNC Blue Value 2026 Tier 5 - Specialty ✓ — ✓ Restricted Access; Limited Distribution PA | QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 3600 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 3000 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold 1500 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold RD CMS Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — — PA
Humana Full Access H5525-034 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice Giveback H5525-035 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-049 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-050 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-070 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5525-083 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health AVA (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring True Choice (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Platinum (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Assist Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Giveback Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Dual (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Value Plus (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Prime (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Enhanced (HMO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 5 - Specialty ✓ — — PA
Blue Medicare PPO Enhanced (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Senior Care (HMO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare (HMO) Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
HumanaChoice Giveback H5216-017 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HumanaChoice H5216-211 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health smartHMO (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Platinum Select (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature Extra (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — — PA
Aetna Medicare Signature (PPO) Tier 5 - Specialty ✓ — — PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Select (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Savings (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring Preferred Plus (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthSpring TotalCare (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Plan II (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Vitality Plan (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 15 hours, 55 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Secure Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health 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
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
Silver Classic Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | 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
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