Ludent

Generic: sodium fluoride

0.55 MG — Chewable Tablet

Also known as: sodium fluoride
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Clear Silver with $0 Insulin Options
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Elite Bronze
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Everyday Bronze
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Complete Gold with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Focused Silver with Atrium Health
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Standard Gold + Vision + Adult Dental
via sodium fluoride 		Tier 0 - $0 Preventive — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Signature + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via sodium fluoride 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Dentagel 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Dentagel 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Dentagel 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Jun 1, 2026  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Sodium Fluoride 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Sodium Fluoride 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Sodium Fluoride 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Sodium Fluoride 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Sodium Fluoride 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Clinpro 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Sodium Fluoride 5000 Ppm 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Clinpro 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Clinpro 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Clinpro 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Clinpro 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Denta 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Denta 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Denta 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Denta 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Denta 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Dentagel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Dentagel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Dentagel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Dentagel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Dentagel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Fluoridex Daily Defense 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Fluoridex Daily Defense 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Fluoridex Daily Defense 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Fluoridex Daily Defense 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Fluoridex Daily Defense 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Fluoridex Enhanced Whiten 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Fluoridex Enhanced Whiten 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Fluoridex Enhanced Whiten 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Fluoridex Enhanced Whiten 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Fluoridex Enhanced Whiten 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Fluorimax 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Fluorimax 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Fluorimax 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Fluorimax 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Fluorimax 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Just Right 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Just Right 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Just Right 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Just Right 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Just Right 5000 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Sf 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Sf 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Sf 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Sf 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Sf 5000 Plus 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via sodium fluoride 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via sodium fluoride 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via sodium fluoride 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via sodium fluoride 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via sodium fluoride 		Tier 1 - Lowest Cost Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Dentagel 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Fluoridex Daily Defense 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Elite Saver Plus | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
AIAN Cost Share
via sodium fluoride 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
AIAN Cost Share
via Nafrinse 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Gold Classic Standard
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Classic Standard
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Gold Elite Saver Plus Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Classic Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Gold Classic Standard
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Classic
via sodium fluoride 		Tier 2 - Generic — — — None
Secure
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Classic 4700
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via sodium fluoride 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via sodium fluoride 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via sodium fluoride 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
AIAN Cost Share
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Flura-Drops 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Flura-Drops 		Tier 2 - Generic — — — None
Secure
via Flura-Drops 		Tier 2 - Generic — — — None
Silver Classic
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Flura-Drops 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Flura-Drops 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Nafrinse 		Tier 2 - Generic — — — None
Silver Classic Standard
via Nafrinse 		Tier 2 - Generic — — — None
Gold Classic Standard
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Nafrinse 		Tier 2 - Generic — — — None
Silver Classic
via Nafrinse 		Tier 2 - Generic — — — None
Secure
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Nafrinse 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Nafrinse 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Nafrinse 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 45 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ Dental + Vision (No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Bronze Standard (No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Gold Standard (No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Silver Standard (No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via sodium fluoride 		Tier 0 - $0 Preventive — — — None
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