mafenide

50 MG

Methylated Sulfonamide Antibacterial

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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: 10 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Silver
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Gold
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Silver with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Silver + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Gold + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Streamlined Silver with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Streamlined Silver
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred — — — None
Everyday Bronze Tier 4 - Non-Preferred — — — None
Elite Bronze Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze Tier 4 - Non-Preferred — — — None
Signature Silver Tier 4 - Non-Preferred — — — None
Signature Gold Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Signature Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred — — — None
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Streamlined Silver Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 10 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 10 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver 5000 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver 3600 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 10 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
Aetna Medicare Signature (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
Source: CMS QHP JSON  ·  Checked: 10 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Simple Diabetes | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Classic 4700
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Gold Elite Saver Plus
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Classic Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Classic Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Gold Classic Standard
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Classic Standard | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Classic Standard | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Gold Classic Standard | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Secure | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Classic | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Gold Elite Saver Plus | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AIAN Cost Share
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
AIAN Cost Share | with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Secure
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Silver Classic
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 10 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
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