nilotinib hcl
50 mg, 150 mg, 200 mg — Capsule
Also known as:
Nilotinib HCl Oral Capsule
nilotinib hcl cap 50 mg (base equivalent), 150 mg (base equivalent), 200 mg (base equivalent)
Nilotinib Hcl 50 Mg Capsule
Nilotinib Hcl 150 Mg Capsule
Nilotinib Hcl 200 Mg Capsule
nilotinib hcl caps 50mg, 150mg, 200mg
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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.
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 4 - Preferred Specialty | ✓ | — | — | PA |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 112 per 28 days | PA | QL |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 112 per 28 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 120 per 30 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 112 per 28 days | PA | QL |