Premarin
Generic: estrogens, conjugated
0.625 MG — Tablet
Also known as:
PREMARIN TABS .3MG, .45MG, .625MG, .9MG, 1.25MG
estrogens, conjugated (USP)
Premarin 0.3 Mg Tablet
Premarin 0.45 Mg Tablet
Premarin 0.625 Mg Tablet
Premarin 0.9 Mg Tablet
Premarin 1.25 Mg Tablet
PREMARIN TABS .3MG, .45MG, .625MG, .9MG,
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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)
58 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Clear Silver with $0 Insulin Options
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Gold + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Silver + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Elite Bronze + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Silver with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Elite Bronze with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Gold | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Silver | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Expanded Bronze | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Elite Bronze | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Everyday Bronze | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Complete Gold | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 3 - Preferred Brand | — | — | ✓ | QL |
| Standard Gold with Atrium Health | Tier 3 - Preferred Brand | — | — | ✓ | QL |
Blue Cross Blue Shield Federal
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBS Federal Standard Option 2026
via estrogens, conjugated |
Tier 1 - Generic | — | — | — | None |
|
BCBS Federal Focus 2026
via estrogens, conjugated |
Tier 1 - Generic | — | — | — | None |
|
BCBS Federal Basic Option 2026
via estrogens, conjugated |
Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 3 - Non-Preferred Brand | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 3 - Non-Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Care 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 3 - High Cost Brand | — | — | — | None |
| BCBSNC Blue Value 2026 | Tier 3 - High Cost Brand | — | — | — | None |
Cigna
1 planMedicare Part D
204 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Longevity Health Plan (HMO I-SNP)
via estrogens, conjugated (USP) |
Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential 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 Dual Plan (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via estrogens, conjugated (USP) |
Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
PruittHealth Premier (HMO I-SNP)
via estrogens, conjugated (USP) |
Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
NHC Advantage (HMO I-SNP)
via estrogens, conjugated (USP) |
Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Senior Care (HMO I-SNP)
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | — | None |
|
Liberty Medicare Advantage (HMO C-SNP)
via estrogens, conjugated (USP) |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare Enhanced (HMO-POS)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Select (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Plus (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| 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 005 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 |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
|
Blue Medicare PPO Enhanced (PPO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Blue Medicare Essential Plus (HMO-POS)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Blue Medicare Choice (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Blue Medicare Essential (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Experience Health Medicare Advantage (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health Platinum (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health Platinum (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health smartHMO (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health Platinum Select (HMO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
|
Alignment Health AVA (PPO)
via estrogens, conjugated (USP) |
Tier 3 - Preferred Brand | — | — | — | None |
| Troy Medicare (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
|
HumanaChoice Giveback H5525-035 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Enhanced (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Enhanced (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature Care (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Prime (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Value Plus (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Dual (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (HMO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
|
HumanaChoice H5525-049 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice H5525-050 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice H5525-070 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice H5525-083 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H6622-025 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H6622-026 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H1036-335 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice Giveback H5216-017 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice H5216-211 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Full Access H5525-034 (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H6622-057 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H6622-061 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Choice H8145-004 (PFFS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature Giveback (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Signature Extra (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
|
Aetna Medicare Enhanced (PPO)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H1036-137 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 30 per 30 days | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H1036-233 (HMO-POS)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via estrogens, conjugated (USP) |
Tier 4 - Non-Preferred | — | — | — | None |
NC Medicaid PDL
1 planNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - 80/20 Plus PPO 2026
via estrogens, conjugated |
Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via estrogens, conjugated |
Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via estrogens, conjugated |
Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Not Covered | — | — | — | None |