mesalamine

Generic: Pentasa

1.2 gram, 250 mg, 500 mg, 800 mg — Delayed Release Capsule

GASTROINTESTINAL AGENTS- MISC.

Also known as: mesalamine er oral capsule 0 .375 Apriso, Pentasa Rowasa Canasa SF Rowasa mesalamine cap dr 400 mg mesalamine cap er 24hr 0.375 gm mesalamine enema 4 gm mesalamine tab delayed release 800 mg mesalamine tab delayed release 1.2 gm Mesalamine 800 Mg Dr Tablet Mesalamine Er 0.375 Gram Capsule Mesalamine Er 500 Mg Capsule MESALAMINE ER LIALDA PENTASA
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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: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred — — ✓ QL
Complete Gold Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Gold Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via Lialda 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Lialda 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Canasa 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Canasa 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Canasa 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Canasa 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Canasa 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Lialda 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Lialda 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Lialda 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Lialda 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Lialda 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Delzicol 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Delzicol 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Delzicol 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Delzicol 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Delzicol 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via Apriso 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Apriso 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Apriso 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Apriso 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Apriso 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 3 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Blue Medicare Choice (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Blue Medicare Essential (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Experience Health Medicare Advantage (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health Platinum (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health smartHMO (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health Platinum Select (HMO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health AVA (PPO)
via Pentasa 		Tier 4 - Non-Preferred — — ✓ 480 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HealthTeam Advantage Plan I (PPO) 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — ✓ 120 per 30 days QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via SF Rowasa 		Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Pentasa 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Lialda 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Rowasa 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Canasa 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026 Non-Preferred — ✓ — ST
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via Rowasa 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Rowasa 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Rowasa 		Tier 3 - Non-Preferred Brand — — — None
Source: Excel (XLSX)  ·  Formulary date: Jan 5, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 22 hours, 25 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 3 - Mid-Range Cost — — ✓ QL
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