lamotrigine

Generic: Subvenite

25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg — Tablet

ANTICONVULSANTS

Also known as: lamotrigine oral tablet lamotrigine oral tablet chewable Lamictal XR lamotrigine kit 25mg; tb24 250mg; tbdp 25mg lamotrigine tab 25 mg (42) & 100 mg (7) starter kit lamotrigine tab 84 x 25 mg & 14 x 100 mg starter kit lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit lamotrigine tab disint 42 x 50mg & 14 x 100mg titration kit lamotrigine tab chewable dispersible 5 mg, 25 mg lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg Lamotrigine 5 Mg Dispersible Tablet Lamotrigine 25 Mg Dispersible Tablet Lamotrigine 25 Mg Odt Tablet Lamotrigine 50 Mg Odt Tablet Lamotrigine 100 Mg Odt Tablet Lamotrigine 200 Mg Odt Tablet Lamotrigine 25 Mg Tablet Lamotrigine 100 Mg Tablet Lamotrigine 150 Mg Tablet Lamotrigine 200 Mg Tablet Lamotrigine Tablet Starter Kit-Blue Lamotrigine Tablet Starter Kit-Green Lamotrigine Tablet Starter Kit-Orange Lamotrigine Er 25 Mg Tablet Lamotrigine Er 50 Mg Tablet Lamotrigine Er 100 Mg Tablet Lamotrigine Er 200 Mg Tablet Lamotrigine Er 250 Mg Tablet Lamotrigine Er 300 Mg Tablet SUBVENITE lamotrigine tab 25 mg (42) & 100 mg (7) starter lamotrigine tab 84 x 25 mg & 14 x 100 mg lamotrigine tab disint 21 x 25 mg & 7 x 50 mg lamotrigine tab disint 25 (14) & 50 mg (14) & 100 lamotrigine tab disint 42 x 50mg & 14 x 100mg LAMOTRIGINE TAB START KIT-BLUE LAMOTRIGINE TAB START KT-ORANG LAMOTRIGINE TAB START KT-GREEN lamoTRIgine ER Oral Tablet Extended Release lamoTRIgine Oral Tablet lamoTRIgine Oral Tablet Chewable
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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: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Clear Silver with $0 Insulin Options
via Subvenite 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Signature Gold
via Subvenite 		Tier 2 - Generic — — — None
Signature Silver
via Subvenite 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via Subvenite 		Tier 2 - Generic — — — None
Elite Bronze
via Subvenite 		Tier 2 - Generic — — — None
Everyday Bronze
via Subvenite 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Subvenite 		Tier 2 - Generic — — — None
Complete Gold
via Subvenite 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Streamlined Silver Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Streamlined Silver
via Subvenite 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via Subvenite 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Subvenite 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze Tier 2 - Generic — — ✓ QL
Signature Silver Tier 2 - Generic — — ✓ QL
Signature Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Subvenite 		Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Lamictal 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Lamictal Xr 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Lamictal Xr 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Lamictal 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Subvenite 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Subvenite 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Lamictal 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Lamictal 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Lamictal 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Lamictal 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Lamictal 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Lamictal Chewable Di 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Lamictal Chewable Di 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Lamictal Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Lamictal Chewable Di 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Lamictal Chewable Di 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Lamictal Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Lamictal Chewable Di 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Lamictal Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Lamictal Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Lamictal Xr 		Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Subvenite 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Subvenite 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Subvenite 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Subvenite 		Tier 1 - Preferred Generic ✓ — ✓ 2160 per 30 days PA | QL
NHC Advantage (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic ✓ — ✓ 2160 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic ✓ — ✓ 2160 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic ✓ — ✓ 2160 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Subvenite 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Assist Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
HealthSpring Preferred Plus (HMO) Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO) Tier 2 - Generic — — — None
HealthSpring Preferred Select (HMO) Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 2 - Generic — — — None
HealthSpring Preferred (HMO) Tier 2 - Generic — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
HealthSpring True Choice (PPO) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — — None
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Dual (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Senior Care (HMO I-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — ✓ 2160 per 30 days PA | QL
Troy Medicare (HMO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO)
via Subvenite 		Tier 4 - Non-Preferred ✓ — — PA
Humana Full Access H5525-034 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Subvenite 		Tier 4 - Non-Preferred ✓ — ✓ 2160 per 30 days PA | QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS)
via Subvenite 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Subvenite 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health smartHMO (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health Platinum Select (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
DEVOTED CORE 001 NC (HMO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED GIVEBACK 002 NC (HMO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED DUAL 009 NC (HMO D-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED GIVEBACK 012 NC (HMO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
Aetna Medicare Dual (HMO D-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Signature (HMO) 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
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature Extra (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Wellcare Simple Open (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Assist Open (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Giveback Open (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
Alignment Health AVA (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring True Choice (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
DEVOTED CHOICE 001 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE 003 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE 005 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
Blue Medicare PPO Enhanced (PPO)
via Subvenite 		Tier 5 - Specialty — — — None
Blue Medicare Essential Plus (HMO-POS)
via Subvenite 		Tier 5 - Specialty — — — None
Blue Medicare Enhanced (HMO-POS)
via Subvenite 		Tier 5 - Specialty — — — None
Blue Medicare Choice (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Blue Medicare Essential (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Experience Health Medicare Advantage (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Simple (HMO-POS)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
DEVOTED CHOICE 008 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Subvenite 		Tier 5 - Specialty — ✓ — ST
HealthSpring TotalCare (HMO D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring Preferred (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring Preferred Select (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring Preferred Savings (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
HealthSpring Preferred Plus (HMO)
via Subvenite 		Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care (HMO C-SNP) 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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Subvenite 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Subvenite 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Subvenite 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Subvenite 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Lamictal Xr 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Lamictal 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Lamictal 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Lamictal 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via lamotrigine tb24 		Not Covered — — — (applies to NDC None
NC State Health Plan - HDHP 2026
via Lamictal Xr 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via lamotrigine tb24 		Not Covered — — — (applies to NDC None
NC State Health Plan - 80/20 Plus PPO 2026
via lamotrigine tb24 		Not Covered — — — (applies to NDC None
NC State Health Plan - 70/30 Standard PPO 2026
via Lamictal Xr 		Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic ✓ — — PA
AIAN Cost Share | with Atrium Health Tier 2 - Generic ✓ — — PA
AIAN Cost Share Tier 2 - Generic ✓ — — PA
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic ✓ — — PA
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic ✓ — — PA
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Classic | with Atrium Health Tier 2 - Generic ✓ — — PA
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic ✓ — — PA
Secure | with Atrium Health Tier 2 - Generic ✓ — — PA
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic ✓ — — PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic ✓ — — PA
Gold Classic Standard | with Atrium Health Tier 2 - Generic ✓ — — PA
Silver Classic Standard | with Atrium Health Tier 2 - Generic ✓ — — PA
Bronze Classic Standard | with Atrium Health Tier 2 - Generic ✓ — — PA
Gold Classic Standard Tier 2 - Generic ✓ — — PA
Silver Classic Standard Tier 2 - Generic ✓ — — PA
Bronze Classic Standard Tier 2 - Generic ✓ — — PA
Silver Simple Diabetes Tier 2 - Generic ✓ — — PA
Gold Elite Saver Plus Tier 2 - Generic ✓ — — PA
Silver Simple PCP Saver Tier 2 - Generic ✓ — — PA
Bronze Classic 4700 Tier 2 - Generic ✓ — — PA
Secure Tier 2 - Generic ✓ — — PA
Silver Classic Tier 2 - Generic ✓ — — PA
Bronze Elite + PCP Saver Plus Tier 2 - Generic ✓ — — PA
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Subvenite 		Tier 1 - Preferred Generic — — — None
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