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 Mesalamine Oral Capsule Delayed Release Mesalamine Oral Tablet Delayed Release Mesalamine ER Oral Capsule Extended Release
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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: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze Tier 4 - Non-Preferred — — ✓ QL
Standard Silver Tier 4 - Non-Preferred — — ✓ QL
Standard Gold Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Elite 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 + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental 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 + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze 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
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 22 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: Jul 1, 2026  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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 Local 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 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via Mesalamine Dr 		Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Value 2026
via Mesalamine Dr 		Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Mesalamine Dr 		Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Mesalamine Dr 		Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Local 2026
via Mesalamine Dr 		Tier 4 - Higher Cost Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3000 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver 3500 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver 4400 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible
via MESALAMINE ER 		Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (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
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 120 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via MESALAMINE ER 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via MESALAMINE ER 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via MESALAMINE ER 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via MESALAMINE ER 		Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 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
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) 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 TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (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-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
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
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (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-0021 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) 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
UHC Dual Complete NC-D001 (HMO-POS D-SNP) 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
UHC Dual Complete NC-V001 (HMO-POS D-SNP) 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
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — ✓ 120 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 Nursing Home Plan NC-F001 (PPO I-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via MESALAMINE ER 		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
UHC Complete Care NC-25 (HMO-POS C-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via MESALAMINE ER 		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
HealthSpring True Choice (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via MESALAMINE ER 		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 Enhanced (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)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Blue Medicare Choice (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Blue Medicare Essential (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Experience Health Medicare Advantage (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 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
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)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health smartHMO (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health Platinum Select (HMO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 per 30 days QL
Alignment Health AVA (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — ✓ 240 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)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via MESALAMINE ER 		Tier 4 - Non-Preferred — — — None
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)
via MESALAMINE ER 		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
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
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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 22 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 Canasa 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Lialda 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026 Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Rowasa 		Non-Preferred — ✓ — ST
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 2 hours, 22 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: CMS QHP JSON  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Secure | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 Tier 3 - Preferred Brand ✓ — — PA
Secure Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Classic | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 2 hours, 22 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: Jun 23, 2026  ·  Checked: 2 hours, 22 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 3 - Preferred Brand — — ✓ QL
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