Lenvima
Generic: lenvatinib
4 Mg, 10 Mg, 10 Mg — Capsule
Also known as:
Lenvima Oral Capsule Therapy Pack 10 & 4 Mg, 10 Mg, 10 Mg & 2 X
LENVIMA 4 MG DAILY DOSE CPPK 4MG
LENVIMA 8 MG DAILY DOSE CPPK 4MG
LENVIMA 10 MG DAILY DOSE CPPK 10MG
LENVIMA 12MG DAILY DOSE CPPK 4MG
LENVIMA 20 MG DAILY DOSE CPPK 10MG
LENVIMA CAP 14 MG
LENVIMA CAP 18 MG
LENVIMA CAP 24 MG
Lenvima 10 Mg Daily Dose
Lenvima 12Mg Daily Dose
Lenvima 14 Mg Daily Dose
Lenvima 18 Mg Daily Dose
Lenvima 20 Mg Daily Dose
Lenvima 24 Mg Daily Dose
Lenvima 4 Mg Daily Dose
Lenvima 8 Mg Daily Dose
Lenvima 4 Mg Capsule
Lenvima 12 Mg Daily Dose
lenvatinib
Lenvima (14 MG Daily Dose) Oral Capsule Therapy Pack
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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)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Silver Signature + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Gold Signature + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Gold Premier + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AmeriHealth Caritas Next Silver Essential + No Referrals
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Local 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Advantage 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Care 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Value 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver CMS Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Medicare Part D
280 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
NHC Advantage (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
PruittHealth Premier (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Liberty Medicare Dual Plan (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring True Choice (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring Preferred (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring Preferred Select (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring Preferred Savings (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthSpring Preferred Plus (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CORE 001 NC (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Liberty Medicare Advantage (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Simple Open (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Simple (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Giveback Open (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Blue Medicare Enhanced (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Blue Medicare Choice (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Blue Medicare Essential (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Experience Health Medicare Advantage (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health Platinum (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health smartHMO (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health Platinum Select (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Alignment Health AVA (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HealthTeam Advantage Plan I (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Plan II (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Vitality Plan (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
Troy Medicare (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Assist Open (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Dual Access (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Erickson Advantage Signature (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Erickson Advantage Freedom (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Erickson Advantage Liberty (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Dual (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Value Plus (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Prime (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature Care (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Enhanced (HMO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Enhanced (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Enhanced (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature Extra (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature Giveback (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
|
HumanaChoice Giveback H5216-017 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice H5216-211 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Full Access H5525-034 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice Giveback H5525-035 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice H5525-049 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice H5525-050 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice H5525-070 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
HumanaChoice H5525-083 (PPO)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H6622-025 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H6622-026 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H6622-057 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H6622-061 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Choice H8145-004 (PFFS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Senior Care (HMO I-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H1036-137 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H1036-233 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
|
Humana Gold Plus H1036-335 (HMO-POS)
via Lenvima (8 MG Daily Dose) |
Tier 5 - Specialty | ✓ | — | ✓ 60 per 30 days | PA | QL |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - HDHP 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |