phenobarbital
Generic: phenobarbital elixir
100 mg, 15 mg, 16.2 mg, 20 mg/5 mL (4 mg/mL), 20 mg/5 mL (5 mL), 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg — Tablet
Also known as:
phenobarbital oral elixir 20 mg/5ml
phenobarbital oral tablet
Phenobarbital 20 Mg/5 Ml Oral Solution
Phenobarbital 30 Mg/7.5 Ml Oral Solution
Phenobarbital 60 Mg/15 Ml Oral Solution
Phenobarbital 30 Mg Tablet
Phenobarbital 15 Mg Tablet
Phenobarbital 16.2 Mg Tablet
Phenobarbital 32.4 Mg Tablet
Phenobarbital 60 Mg Tablet
Phenobarbital 64.8 Mg Tablet
Phenobarbital 97.2 Mg Tablet
Phenobarbital 100 Mg Tablet
PHENobarbital Oral Tablet
PHENobarbital Oral Elixir
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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 |
|---|---|---|---|---|---|
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | 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 |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver | Tier 2 - Generic | — | — | — | None |
| Signature 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 |
| Signature Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 4 - Non-Preferred | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Local 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Care 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Value 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3600 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
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 | — | — | ✓ 120 per 30 days | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 120 per 30 days | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 120 per 30 days | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 120 per 30 days | QL |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 120 per 30 days | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 120 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - 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 |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | ✓ | — | — | PA |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | 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 |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Troy Medicare (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| 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 |
| 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 |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| 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 |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring Preferred Select (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring Preferred Savings (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring Preferred Plus (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 120 per 30 days | PA | QL |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | 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 |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Secure | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | 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 |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | 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 Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
TRICARE
1 planUnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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 Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, 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 Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |