lamotrigine

Generic: Subvenite

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

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.

Ambetter (Centene)

58 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Focused Silver with Atrium Health + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug 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
Standard Expanded Bronze	Tier 2 - Generic	—	—	✓	QL
Standard Silver	Tier 2 - Generic	—	—	✓	QL
Standard Gold	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Silver with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Gold with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug 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
Standard Expanded Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Silver + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Complete Gold via Subvenite	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Subvenite	Tier 2 - Generic	—	—	—	None
Everyday Bronze via Subvenite	Tier 2 - Generic	—	—	—	None
Elite Bronze via Subvenite	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Silver via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Gold via Subvenite	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Gold with Atrium Health via Subvenite	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Complete Gold	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze 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
Standard Gold with Atrium Health + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Silver with Atrium Health + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Gold + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Standard Silver + Vision + Adult Dental via Subvenite	Tier 2 - Generic	—	—	—	None
Standard 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

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 2 - Generic	—	—	—	None

Blue Cross Blue Shield Federal

9 plans

Source: PDF · Formulary date: Aug 7, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic 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 Subvenite	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Subvenite	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Lamictal	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

15 plans

Source: PDF · Formulary date: Aug 1, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Value 2026 via Lamictal	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Local 2026 via Lamictal	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Care 2026 via Lamictal	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Advantage 2026 via Lamictal	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Lamictal	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Lamictal Xr	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Lamictal Xr	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Lamictal Xr	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 Chewable Di	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 Care 2026 via Lamictal Chewable Di	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Lamictal Chewable Di	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Lamictal Xr	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Lamictal Xr	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

40 plans

Source: PDF · Formulary date: Aug 21, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3500 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver 3500 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 Bronze 6500 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Subvenite	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 myDiabetesCare Bronze 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 RD 6000 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Subvenite	Tier 2 - Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Subvenite	Tier 2 - Generic	—	—	—	None

Medicare Part D

280 plans

Source: CMS QHP JSON · Formulary date: Aug 19, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (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) 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
NHC Advantage (HMO I-SNP) via Subvenite	Tier 1 - Preferred Generic	✓	—	✓ 2160 per 30 days	PA \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 2 - 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 Liberty (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	—	None
Wellcare Assist Open (PPO)	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO)	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 2 - Generic	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO)	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-27 (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-25 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO)	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 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
Blue Medicare PPO Enhanced (PPO)	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 Giveback from UHC NC-13 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (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-0009 (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
Erickson Advantage Signature (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED C-SNP PREMIUM 016 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 014 NC (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Subvenite	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (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
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
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
Liberty Medicare Advantage (HMO C-SNP) via Subvenite	Tier 4 - Non-Preferred	✓	—	✓ 2160 per 30 days	PA \| QL
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
HumanaChoice H5525-083 (PPO)	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 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
Humana Full Access H5525-034 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	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
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 Signature (PPO)	Tier 5 - Specialty	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 5 - Specialty	—	—	—	None
HealthSpring True Choice (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Alignment Health AVA (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Aetna Medicare Signature (HMO)	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 Signature Care (HMO)	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 Dual Liberty (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 Access (HMO-POS D-SNP) via Subvenite	Tier 5 - Specialty	—	—	—	None
Wellcare Simple (HMO-POS) via Subvenite	Tier 5 - Specialty	—	—	—	None
Experience Health Medicare Advantage (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 5 - Specialty	—	—	—	None
Alignment Health Platinum (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Blue Medicare Essential (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Blue Medicare Choice (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Subvenite	Tier 5 - Specialty	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Subvenite	Tier 5 - Specialty	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring Preferred Plus (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring Preferred Savings (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring Preferred Select (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring Preferred (HMO) via Subvenite	Tier 5 - Specialty	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Subvenite	Tier 5 - Specialty	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE 008 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE 005 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE 003 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
DEVOTED CHOICE 001 NC (PPO) via Subvenite	Tier 5 - Specialty	—	✓	—	ST
Healthy Blue + Medicare (HMO-POS D-SNP) via Subvenite	Tier 5 - Specialty	—	—	—	None
Wellcare Giveback Open (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Wellcare Assist Open (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Subvenite	Tier 5 - Specialty	—	—	—	None
Wellcare Simple Open (PPO) via Subvenite	Tier 5 - Specialty	—	—	—	None

NC Medicaid PDL

1 plan

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	—	—	—	None

NC State Health Plan

15 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 53 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 - HDHP 2026	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 - HDHP 2026 via Subvenite	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 - 80/20 Plus PPO 2026 via Subvenite	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via lamotrigine tb24	Not Covered	—	—	— (applies to NDC	None
NC State Health Plan - HDHP 2026 via lamotrigine tb24	Not Covered	—	—	— (applies to NDC	None
NC State Health Plan - HDHP 2026 via Lamictal	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 - 80/20 Plus PPO 2026 via Lamictal Xr	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Lamictal Xr	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Lamictal Xr	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via lamotrigine tb24	Not Covered	—	—	— (applies to NDC	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AIAN Cost Share \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Secure \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Classic 4700 \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Classic \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Simple Diabetes \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Classic Standard	Tier 2 - Generic	✓	—	—	PA
Silver Simple PCP Saver \| with Atrium Health	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
Gold Elite Saver Plus \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Simple Diabetes \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Classic	Tier 2 - Generic	✓	—	—	PA
Secure	Tier 2 - Generic	✓	—	—	PA
Bronze Classic Standard \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Gold Classic Standard	Tier 2 - Generic	✓	—	—	PA
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Classic Standard \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Gold Classic Standard \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Bronze Classic 4700	Tier 2 - Generic	✓	—	—	PA
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Silver Classic Standard	Tier 2 - Generic	✓	—	—	PA
AIAN Cost Share	Tier 2 - Generic	✓	—	—	PA
Bronze Elite + PCP Saver Plus	Tier 2 - Generic	✓	—	—	PA

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	—	—	—	None

UnitedHealthcare

34 plans

Source: PDF · Formulary date: Aug 25, 2026 · Checked: 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Standard (No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
54332NC0030042 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, Dental + Vision, No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, 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 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060008 via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060010	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060009	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060008	Tier 1 - Preferred Generic	—	—	—	None
54332NC0030042	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060009 via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060010 via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard (No Referrals) via Subvenite	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, 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+ Dental + Vision (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, 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 Bronze Essential ($0 Virtual Urgent Care, No Referrals via Subvenite	Tier 1 - Preferred Generic	—	—	—	None