Orthovisc
Generic: sodium hyaluronate
30 MG — Prefilled Syringe
Also known as:
sodium hyaluronate
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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)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Complete Gold with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Streamlined Silver
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Everyday Bronze
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Elite Bronze
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Clear Silver with $0 Insulin Options
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Expanded Bronze
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Silver
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Gold
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Everyday Bronze with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Elite Bronze with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Focused Silver with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Streamlined Silver with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Expanded Bronze with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Silver with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Gold with Atrium Health
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Complete Gold + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Everyday Bronze + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Elite Bronze + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Expanded Bronze + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Silver + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Complete Gold
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Gold + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Silver with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Signature Gold with Atrium Health + Vision + Adult Dental
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
|
Enhanced CHF Heart Care Silver $0 Rx Options
via Provisc |
Tier 4 - Non-Preferred | ✓ | — | — | PA |
AmeriHealth Caritas NC
22 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Premier + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Gel-Syn |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
|
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Euflexxa |
Tier 5 - Specialty | ✓ | — | — | PA |
Oscar Health
162 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Classic | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Classic | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010074 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010075 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010076 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010077 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010078 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010079 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010080 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010081 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010082 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010083 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010084 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010085 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus with Adult Dental & Vision | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Core Plan | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Core Plan | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes with Adult Dental & Vision | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010108 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010109 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010110 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010111 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010112 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010113 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010114 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010115 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010116 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| 69803NC0010117 | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010074
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010075
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010076
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010077
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010078
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010079
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010080
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010081
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010082
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010083
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010084
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010085
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010108
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010109
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010110
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010111
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010112
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010113
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010114
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010115
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010116
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010117
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Monovisc |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010074
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010075
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010076
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010077
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010078
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010079
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010080
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010081
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010082
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010083
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010084
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010085
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Core Plan | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010108
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010109
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010110
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010111
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010112
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010113
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010114
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010115
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010116
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
69803NC0010117
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via Euflexxa |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |