mirtazapine
7.5mg, 15mg, 30mg, 45mg — Tablet
Also known as:
mirtazapine oral tablet
mirtazapine oral tablet dispersible
mirtazapine tabs 7.5mg, 15mg, 30mg, 45mg; tbdp 15mg, 30mg, 45mg
mirtazapine tab 7.5 mg, 45 mg
mirtazapine tab 15 mg, 30 mg
Mirtazapine 15 Mg Odt Tablet
Mirtazapine 30 Mg Odt Tablet
Mirtazapine 45 Mg Odt Tablet
Mirtazapine 7.5 Mg Tablet
Mirtazapine 15 Mg Tablet
Mirtazapine 30 Mg Tablet
Mirtazapine 45 Mg Tablet
mirtazapine tabs 7.5mg, 15mg, 30mg, 45mg;
Mirtazapine Oral Tablet Disintegrating
Mirtazapine Oral Tablet
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Remeron |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Remeron |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Value 2026
via Remeron |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Advantage 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Local 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Care 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Value 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Advantage 2026
via Remeron |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Remeron |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Local 2026
via Remeron |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Care 2026
via Remeron |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 30 per 30 days | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 30 per 30 days | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
NC State Health Plan
6 plans| 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 - HDHP 2026
via Remeron |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Remeron |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Remeron |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | — | None |
| Secure | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
UnitedHealthcare
13 plans| 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 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |