Isentress

Generic: raltegravir

100 MG — Chewable Tablet

ANTIVIRALS

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.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug 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
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug 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
Standard Expanded Bronze Tier 4 - Non-Preferred — — ✓ QL
Standard Silver Tier 4 - Non-Preferred — — ✓ QL
Standard 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
Source: CMS QHP JSON  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Brand-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 4400 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Community Plan (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 Dual Plan (HMO D-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
NHC Advantage (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
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 60 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 Nursing Home Plan NC-F001 (PPO I-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
UHC Dual Complete NC-S2 (PPO D-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-0001 (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
AARP Medicare Advantage from UHC NC-0016 (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
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
AARP Medicare Advantage from UHC NC-26 (HMO-POS) 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 Guardian (HMO-POS I-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-25 (HMO-POS C-SNP) 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
UHC Complete Care NC-28 (HMO-POS C-SNP) 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
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
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-137 (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 H1036-233 (HMO-POS) 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 Giveback H1036-318 (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 H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 300 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
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
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
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
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 5 - Specialty — — — None
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
Blue Medicare Essential (HMO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-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
Alignment Health AVA (PPO) 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Signature Care (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Prime (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Value Plus (HMO) Tier 5 - Specialty — — — None
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
Senior Care (HMO I-SNP) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 5 - Specialty — — — None
HealthSpring Preferred Plus (HMO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
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
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 5 - Specialty — — — None
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
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty — — — None
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty — — — None
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 Preferred Savings (HMO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO) 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
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO) Tier 5 - Specialty — — — None
Wellcare Simple (HMO-POS) Tier 5 - Specialty — — — None
Wellcare Giveback Open (PPO) Tier 5 - Specialty — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 5 - Specialty — — — None
Wellcare Assist Open (PPO) Tier 5 - Specialty — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 5 - Specialty — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 5 - Specialty — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 5 - Specialty — — ✓ 60 per 30 days QL
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
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature Extra (PPO) Tier 5 - Specialty — — — None
Source: CMS QHP JSON  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Elite Saver Plus | 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
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | 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 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 Elite + PCP Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Tier 3 - Preferred Brand — — ✓ QL
Secure Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 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
Secure | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 20 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Standard (No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, 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 Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard (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 Bronze Standard+ Dental + Vision (No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Standard (No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 4 - Non-Preferred — — ✓ QL
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