macitentan
Generic: Opsumit
10 MG — Tablet
Endothelin Receptor Antagonist
Also known as:
macitentan tabs 10mg
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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.
Blue Cross Blue Shield Federal
8 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBS Federal Focus 2026
via Opsumit |
Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Standard Option 2026
via Opsumit |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Basic Option 2026
via Opsumit |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Basic Option 2026
via Opsynvi |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
|
BCBS Federal Standard Option 2026
via Opsynvi |
Tier 5 - Non-Preferred Specialty | ✓ | — | — | PA |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Advantage 2026
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Value 2026
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Care 2026
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
BCBSNC Blue Local 2026
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Medicare Part D
171 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Opsynvi |
Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Opsumit |
Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Opsumit |
Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Opsumit |
Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
DEVOTED CORE 001 NC (HMO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| 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 |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| 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 |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | 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 |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Select (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Savings (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Plus (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthTeam Advantage Plan I (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
HealthTeam Advantage Plan II (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
HealthTeam Advantage Vitality Plan (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Troy Medicare (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CORE 001 NC (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
HealthSpring True Choice (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ 30 per 30 days | PA | QL |
NC Medicaid PDL
2 plansNC State Health Plan
9 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - HDHP 2026 | Tier 4 - Specialty Generic | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Opsumit |
Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - HDHP 2026
via Opsumit |
Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Opsumit |
Tier 5 - Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Opsynvi |
Not Covered | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via Opsynvi |
Not Covered | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Opsynvi |
Not Covered | — | — | — | None |
Oscar Health
162 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010074
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010075
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010076
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010077
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010078
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010079
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010080
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010081
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010082
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010083
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010084
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010085
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010108
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010109
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010110
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010111
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010112
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010113
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010114
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010115
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010116
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010117
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010074
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010075
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010076
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010077
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010078
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010079
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010080
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010081
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010082
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010083
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010084
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010085
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010108
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010109
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010110
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010111
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010112
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010113
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010114
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010115
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010116
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010117
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Opsynvi |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010074 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010075 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010076 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010077 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010078 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010079 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010080 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010081 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010082 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010083 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010084 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010085 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus with Adult Dental & Vision | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Core Plan | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Core Plan | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes with Adult Dental & Vision | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010108 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010109 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010110 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010111 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010112 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010113 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010114 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010115 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010116 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010117 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
TRICARE
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| TRICARE Uniform Formulary 2026 | Tier 1 - Generic Formulary | ✓ | — | — | PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED |
|
TRICARE Uniform Formulary 2026
via Opsumit |
Tier 2 - Brand Formulary | ✓ | — | — | PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED |
|
TRICARE Uniform Formulary 2026
via Opsynvi |
Tier 3 - Non-Formulary | ✓ | — | — | PA PA: TPA - SELECT MEDICATIONS REQUIRE PRIOR AUTHORIZATION |
UnitedHealthcare
30 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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 Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, 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 Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Opsumit |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |