Prempro 0.45/1.5 28 Day

Generic: estrogens, conjugated (USP

0.45 MG — Tablet

Estrogen

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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: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 19 hours, 18 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze Tier 3 - Preferred Brand — — ✓ QL
Standard Silver Tier 3 - Preferred Brand — — ✓ QL
Standard Gold Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health
via Prempro 0.625/2.5 28 Day 		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
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
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Silver + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Gold
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Silver
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Elite Bronze
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — ✓ QL
Complete Gold Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze Tier 3 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 19 hours, 18 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		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
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		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
Liberty Medicare Dual Plan (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Premphase 28 Day 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		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 TotalCare (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Prempro 0.3/1.5 28 Day 		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
HealthSpring Preferred (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Prempro 0.3/1.5 28 Day 		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 Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Prempro 0.3/1.5 28 Day 		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 Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		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
Troy Medicare (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Premphase 28 Day 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP) Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) 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)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Liberty (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Freedom (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Signature (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Liberty (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Freedom (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Signature (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
HealthTeam Advantage Plan I (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Prempro 0.3/1.5 28 Day 		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
Erickson Advantage Liberty (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Freedom (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Signature (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Liberty (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Freedom (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Signature (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Premphase 28 Day 		Tier 4 - Non-Preferred — — ✓ 28 per 28 days QL
Aetna Medicare Signature (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Prempro 0.3/1.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.3/1.5 28 Day 		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
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (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 Extra (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 Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/2.5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Prempro 0.625/5 28 Day 		Tier 4 - Non-Preferred — — — None
Something not right?