milnacipran HCl

100 mg, 12.5 mg, 12.5 mg (5)-25 mg (8)-50 mg (42), 25 mg, 50 mg — Tablet

ANTIDEPRESSANTS AND NON-OPIOID PAIN SYNDROME AGENTS

Also known as: milnacipran hcl tabs 12.5mg, 25mg, 50mg, 100mg milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak milnacipran hcl tabs 12.5mg, 25mg, 50mg, milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & SAVELLA Milnacipran HCl Oral Tablet Milnacipran HCl Oral Miscellaneous

Compare Prices

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

63 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 12 hours, 2 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Signature Silver + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Gold + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Silver with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Gold with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Streamlined Silver via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Streamlined Silver with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Enhanced CHF Heart Care Silver $0 Rx Options via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Focused Silver with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Complete Gold with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Silver with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Gold with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Complete Gold via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Everyday Bronze via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Elite Bronze via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Expanded Bronze via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Silver via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Gold via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Signature Expanded Bronze + Vision + Adult Dental via milnacipran hydrochloride	Tier 2 - Generic	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Expanded Bronze + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Silver + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Gold + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Silver with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Gold with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Expanded Bronze via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Silver via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Gold via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Silver with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Signature Gold with Atrium Health via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Savella	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL

AmeriHealth Caritas NC

39 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Savella	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	—	✓	QL

Blue Cross Blue Shield Federal

5 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	✓	QL
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	✓	QL
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	✓	QL
BCBS Federal Basic Option 2026 via Savella	Tier 3 - Non-Preferred Brand	—	—	✓	QL
BCBS Federal Standard Option 2026 via Savella	Tier 3 - Non-Preferred Brand	—	—	✓	QL

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Advantage 2026 via Savella Titration Pa	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Savella Titration Pa	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Local 2026 via Savella Titration Pa	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Care 2026 via Savella Titration Pa	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Value 2026 via Savella	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Value 2026 via Savella Titration Pa	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Care 2026 via Savella	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Local 2026 via Savella	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Savella	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL
BCBSNC Blue Advantage 2026 via Savella	Tier 2 - Medium Cost Generic/Brand	—	—	✓	QL

Cigna

40 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Bronze CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Savella	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Savella Titration Pack	Tier 4 - Non-Preferred	—	—	—	None

Medicare Part D

115 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP) via Savella	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Longevity Health Plan (HMO I-SNP) via milnacipran hydrochloride	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Savella Titration Pack	Tier 1 - Preferred Generic	—	—	✓ 110 per 365 days	QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Savella Titration Pack	Tier 1 - Preferred Generic	—	—	✓ 110 per 365 days	QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Savella Titration Pack	Tier 1 - Preferred Generic	—	—	✓ 110 per 365 days	QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Savella	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Savella	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Savella	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Longevity Health Plan (HMO I-SNP) via Savella Titration Pack	Tier 1 - Preferred Generic	—	—	✓ 55 per 180 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	✓ 60 per 30 days	QL
Troy Medicare (HMO) via milnacipran hydrochloride	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via milnacipran hydrochloride	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO)	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via milnacipran hydrochloride	Tier 2 - Generic	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 110 per 365 days	QL
HealthTeam Advantage Plan II (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 110 per 365 days	QL
HealthTeam Advantage Vitality Plan (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 110 per 365 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Savella	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 110 per 365 days	QL
Wellcare Simple (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Simple Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Assist Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Giveback Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Vitality Plan (PPO) via Savella	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Plan II (PPO) via Savella	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HealthTeam Advantage Plan I (PPO) via Savella	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Simple Open (PPO) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Assist Open (PPO) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Giveback Open (PPO) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple (HMO-POS) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via milnacipran hydrochloride	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Savella	Tier 3 - Preferred Brand	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Simple Open (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Assist Open (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Wellcare Giveback Open (PPO) via Savella Titration Pack	Tier 3 - Preferred Brand	—	—	✓ 55 per 180 days	QL
Troy Medicare (HMO) via Savella Titration Pack	Tier 4 - Non-Preferred	—	✓	—	ST
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Savella Titration Pack	Tier 4 - Non-Preferred	—	✓	—	ST
AmeriHealth Caritas VIP Care (HMO D-SNP) via Savella Titration Pack	Tier 4 - Non-Preferred	—	✓	✓ 55 per 180 days	ST \| QL

NC State Health Plan

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Savella	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Savella	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Savella	Tier 3 - Non-Preferred Brand	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic 4700 \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AIAN Cost Share via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic Standard \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Classic Standard via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic Standard via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic Standard via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Diabetes via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Elite Saver Plus via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Diabetes \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple PCP Saver via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic 4700 via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus via Savella	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA

UnitedHealthcare

30 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 12 hours, 1 minute ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via Savella	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via milnacipran hydrochloride	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL