Leukine
Generic: sargramostim
0.25 MG — Injection
Also known as:
sargramostim
Leukine 250 Mcg Vial
Leukine Injection Solution Reconstituted
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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 |
|---|---|---|---|---|---|
| Complete Gold | Tier 5 - Specialty | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 5 - 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 | ✓ | — | — | PA |
| BCBSNC Blue Care 2026 | Tier 5 - Specialty | ✓ | — | — | PA |
| BCBSNC Blue Value 2026 | Tier 5 - Specialty | ✓ | — | — | PA |
| BCBSNC Blue Advantage 2026 | Tier 5 - Specialty | ✓ | — | — | PA |
| BCBSNC Blue Local 2026 | Tier 5 - Specialty | ✓ | — | — | PA |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver 4400 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze CMS Standard | Tier 5 - Specialty | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | — | — | — | None |
| Connect Silver CMS Standard | Tier 5 - Specialty | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | — | — | — | None |
| Connect Gold CMS Standard | Tier 5 - Specialty | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | — | — | — | None |
Medicare Part D
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Troy Medicare (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
NC Medicaid PDL
1 planUnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Standard (No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 5 - Specialty | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 5 - Specialty | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 5 - Specialty | — | — | — | None |