Isentress
Generic: raltegravir
100 MG — Chewable Tablet
Also known as:
Isentress Oral Packet
raltegravir
Isentress 25 Mg Chewable Tablet
Isentress 100 Mg Chewable Tablet
Isentress 100 Mg Powder Packet
Isentress 400 Mg Tablet
Isentress Oral Tablet Chewable
Isentress Oral Tablet
Raltegravir
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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)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Signature Expanded Bronze with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Everyday Bronze | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Elite Bronze | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Expanded Bronze | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Silver | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Gold | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Elite Bronze with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Complete Gold | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Silver with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Gold with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Elite Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Silver + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Gold + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Streamlined Silver | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Streamlined Silver with Atrium Health | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 4 - Non-Preferred | — | — | ✓ | QL |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Brand-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Brand-Preferred | — | — | ✓ | QL |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Advantage 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Care 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Value 2026 | Tier 3 - High Cost Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Gold RD CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver 5000 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver 3600 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Gold CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 3 - Preferred Brand | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 3 - Preferred Brand | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Troy Medicare (HMO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 300 per 30 days | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | — | — | ✓ 60 per 30 days | QL |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple PCP Saver | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Gold Elite Saver Plus | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple Diabetes | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Classic Standard | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Classic Standard | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Gold Classic Standard | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Gold Classic Standard | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Classic 4700 | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Secure | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Classic | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| AIAN Cost Share | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| AIAN Cost Share | with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Silver Classic | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Secure | Tier 3 - Preferred Brand | — | — | ✓ | QL |
UnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | — | None |