Matzim La

Generic: diltiazem

180mg, 240mg, 300mg, 360mg, 420mg — Tablet

Also known as: Cardizem LA Matzim La 180 Mg Tablet Matzim La 240 Mg Tablet Matzim La 300 Mg Tablet Matzim La 360 Mg Tablet Matzim La 420 Mg Tablet matzim la tb24 180mg, 240mg, 300mg, 360mg, 420mg

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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)

68 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Streamlined Silver via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Tiadylt	Tier 2 - Generic	—	—	—	None
Elite Bronze via Tiadylt	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Tiadylt	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Complete Gold via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Tiadylt	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Streamlined Silver via Tiadylt	Tier 2 - Generic	—	—	—	None
Everyday Bronze via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Silver via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Gold via Tiadylt	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Complete Gold via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Gold via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Silver via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Elite Bronze via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via Tiadylt	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Everyday Bronze via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Tiadylt	Tier 2 - Generic	—	—	—	None

AmeriHealth Caritas NC

11 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None

Blue Cross Blue Shield Federal

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026 via Tiadylt	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Tiadylt	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Tiadylt	Tier 1 - Generic	—	—	—	None

Cigna

40 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 3500 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Bronze via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Silver via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Diltiazem	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Bronze	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3600 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Silver	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None

Medicare Part D

506 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Diltiazem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Prime (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO)	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring True Choice (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Savings (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Savings (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Select (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Savings (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HealthSpring Preferred Plus (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Blue Medicare PPO Enhanced (PPO)	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential Plus (HMO-POS)	Tier 2 - Generic	—	—	—	None
Blue Medicare Enhanced (HMO-POS)	Tier 2 - Generic	—	—	—	None
Blue Medicare Choice (HMO)	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential (HMO)	Tier 2 - Generic	—	—	—	None
Experience Health Medicare Advantage (HMO)	Tier 2 - Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Blue Medicare Choice (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Experience Health Medicare Advantage (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Blue Medicare Choice (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Experience Health Medicare Advantage (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Blue Medicare Choice (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Blue Medicare Essential (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Experience Health Medicare Advantage (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Assist Open (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Assist Open (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Full Access H5525-034 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-049 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-050 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-070 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
HumanaChoice H5525-083 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Freedom (HMO-POS)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS)	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Diltiazem	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Erickson Advantage Signature (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Value Plus (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Prime (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Care (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (HMO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Enhanced (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Tiadylt	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Diltiazem	Tier 2 - Generic	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED CORE 001 NC (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health smartHMO (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Platinum Select (HMO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
Alignment Health AVA (PPO) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via diltiazem hydrochloride	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Tiadylt	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via diltiazem hydrochloride	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Diltiazem	Tier 6 - Specialty Plus	—	—	—	None

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Tiadylt	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026	Non-Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via matzim la tb24	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via matzim la tb24	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via matzim la tb24	Not Covered	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Classic \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
AIAN Cost Share via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple PCP Saver via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Gold Elite Saver Plus via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Simple Diabetes via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Secure \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Silver Classic via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Secure via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Classic 4700 via diltiazem hydrochloride	Tier 1 - Preferred Generic	—	—	—	None
Bronze Classic Standard via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via diltiazem hydrochloride	Tier 2 - Generic	—	—	—	None

UnitedHealthcare

34 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 10 hours, 6 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Tiadylt	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via diltiazem hydrochloride	Tier 3 - Preferred Brand	—	—	—	None