lansoprazole
Generic: Prevacid
15 mg, 30 mg — Delayed Release Capsule
Also known as:
Prevacid Rx
Prevacid OTC
Prevacid SoluTab
lansoprazole tab delayed release orally disintegrating 15 mg, 30 mg
Lansoprazole Dr 15 Mg Capsule
Lansoprazole Dr 30 Mg Capsule
PREVACID
Lansoprazole Oral Capsule Delayed Release
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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| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Clear Silver with $0 Insulin Options
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via Prevacid |
Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | ✓ | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | ✓ | — | ST |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Advantage 2026
via Prevacid Solutab |
Tier 2 - Medium Cost Generic/Brand | ✓ | — | — | PA |
|
BCBSNC Blue Value 2026
via Prevacid Solutab |
Tier 2 - Medium Cost Generic/Brand | ✓ | — | — | PA |
|
BCBSNC Blue Care 2026
via Prevacid Solutab |
Tier 2 - Medium Cost Generic/Brand | ✓ | — | — | PA |
|
BCBSNC Blue Local 2026
via Prevacid Solutab |
Tier 2 - Medium Cost Generic/Brand | ✓ | — | — | PA |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Prevacid Solutab |
Tier 2 - Medium Cost Generic/Brand | ✓ | — | — | PA |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| NHC Advantage (HMO I-SNP) | 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 |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (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 |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 42 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 60 per 30 days | QL |
NC Medicaid PDL
1 planOscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| AIAN Cost Share | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| AIAN Cost Share | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Classic | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Secure | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Classic 4700 | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple PCP Saver | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Gold Elite Saver Plus | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple Diabetes | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Secure | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Classic | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Gold Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
TRICARE
1 planUnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Gold Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Bronze Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | ✓ | QL |