quetiapine
100 MG — Tablet
Also known as:
Quetiapine 25 Mg Tablet
Quetiapine 50 Mg Tablet
Quetiapine 100 Mg Tablet
Quetiapine 200 Mg Tablet
Quetiapine 300 Mg Tablet
Quetiapine 400 Mg Tablet
Quetiapine Er 50 Mg Tablet
Quetiapine Er 150 Mg Tablet
Quetiapine Er 200 Mg Tablet
Quetiapine Er 300 Mg Tablet
Quetiapine Er 400 Mg Tablet
Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
2 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBS Federal Standard Option 2026
via Seroquel |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Seroquel |
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 Home with UNC Health Alliance 2026
via Seroquel |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Value 2026
via Seroquel |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Local 2026
via Seroquel |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Care 2026
via Seroquel |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Advantage 2026
via Seroquel |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
Cigna
1 planMedicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 90 per 30 days | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 90 per 30 days | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Troy Medicare (HMO) | Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 90 per 30 days | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 90 per 30 days | QL |
| 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) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | ✓ | — | ✓ 120 per 30 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | ✓ 90 per 30 days | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - HDHP 2026
via Seroquel |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Seroquel |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Seroquel |
Tier 3 - Non-Preferred Brand | — | — | — | None |