Nulev

Generic: hyoscyamine sulfate

0.125 MG — Tablet

Also known as: hyoscyamine sulfate
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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: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 3 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 6500 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Symax-Sl 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Symax-Sl 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Oscimin 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Oscimin 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Oscimin 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Oscimin 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Ed-Spaz 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Ed-Spaz 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 3 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via hyoscyamine sulfate tb12 .375mg 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via hyoscyamine sulfate tb12 .375mg 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via hyoscyamine sulfate tb12 .375mg 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Hyoscyamine Sulfate 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Hyoscyamine Sulfate 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Hyoscyamine Sulfate 		Not Covered — — — None
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 3 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Classic Standard | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010074
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010075
via Oscimin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010076
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010077
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010078
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010079
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010080
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010081
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010082
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010083
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010084
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010085
via Oscimin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Oscimin 		Tier 2 - Generic — — — None
Bronze Simple Diabetes
via Oscimin 		Tier 2 - Generic — — — None
Silver Core Plan
via Oscimin 		Tier 2 - Generic — — — None
Silver Core Plan | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010108
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010109
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010110
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010111
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010112
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010113
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010114
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010115
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010116
via Oscimin 		Tier 2 - Generic — — — None
69803NC0010117
via Oscimin 		Tier 2 - Generic — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Classic
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Secure
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Classic Standard
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Gold Classic Standard
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010074
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010075
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010076
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010077
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010078
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010079
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010080
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010081
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010082
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010083
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010084
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010085
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Simple Diabetes
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Core Plan
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Core Plan | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010108
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010109
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010110
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010111
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010112
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010113
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010114
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010115
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010116
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
69803NC0010117
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Hyoscyamine Sulfate 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
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
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
69803NC0010074 Tier 2 - Generic — — — None
69803NC0010075 Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health Tier 2 - Generic — — — None
69803NC0010076 Tier 2 - Generic — — — None
69803NC0010077 Tier 2 - Generic — — — None
69803NC0010078 Tier 2 - Generic — — — None
69803NC0010079 Tier 2 - Generic — — — None
69803NC0010080 Tier 2 - Generic — — — None
69803NC0010081 Tier 2 - Generic — — — None
69803NC0010082 Tier 2 - Generic — — — None
69803NC0010083 Tier 2 - Generic — — — None
69803NC0010084 Tier 2 - Generic — — — None
69803NC0010085 Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision Tier 2 - Generic — — — None
Bronze Simple Diabetes Tier 2 - Generic — — — None
Silver Core Plan Tier 2 - Generic — — — None
Silver Core Plan | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision Tier 2 - Generic — — — None
69803NC0010108 Tier 2 - Generic — — — None
69803NC0010109 Tier 2 - Generic — — — None
69803NC0010110 Tier 2 - Generic — — — None
69803NC0010111 Tier 2 - Generic — — — None
69803NC0010112 Tier 2 - Generic — — — None
69803NC0010113 Tier 2 - Generic — — — None
69803NC0010114 Tier 2 - Generic — — — None
69803NC0010115 Tier 2 - Generic — — — None
69803NC0010116 Tier 2 - Generic — — — None
69803NC0010117 Tier 2 - Generic — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Classic
via Ed-Spaz 		Tier 2 - Generic — — — None
Secure
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Classic Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Gold Classic Standard
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010074
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010075
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010076
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010077
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010078
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010079
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010080
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010081
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010082
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010083
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010084
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010085
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Simple Diabetes
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Core Plan
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Core Plan | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010108
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010109
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010110
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010111
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010112
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010113
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010114
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010115
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010116
via Ed-Spaz 		Tier 2 - Generic — — — None
69803NC0010117
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Ed-Spaz 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Oscimin 		Tier 2 - Generic — — — None
Silver Classic
via Oscimin 		Tier 2 - Generic — — — None
Secure
via Oscimin 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Oscimin 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Oscimin 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Oscimin 		Tier 2 - Generic — — — None
Silver Classic Standard
via Oscimin 		Tier 2 - Generic — — — None
Gold Classic Standard
via Oscimin 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Oscimin 		Tier 2 - Generic — — — None
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