quetiapine

100 MG — Tablet

Atypical Antipsychotic

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
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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: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via Seroquel 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Seroquel 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 3 minutes ago
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 Advantage 2026
via Seroquel 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Care 2026
via Seroquel 		Tier 1 - Lowest Cost Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health 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 (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
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
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 90 per 30 days QL
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 90 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 90 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
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 Vitality Plan (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
HumanaChoice Giveback H5216-017 (PPO) 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
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
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
UHC Nursing Home Plan NC-F001 (PPO I-SNP) 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
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
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via Seroquel 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 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
Source: CMS QHP JSON  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Classic Tier 2 - Generic — — — None
Secure Tier 2 - Generic — — — None
Bronze Classic 4700 Tier 2 - Generic — — — None
Silver Simple PCP Saver Tier 2 - Generic — — — None
Gold Elite Saver Plus Tier 2 - Generic — — — None
Silver Simple Diabetes Tier 2 - Generic — — — None
Secure | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic Standard Tier 2 - Generic — — — None
Silver Classic Standard Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 18 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Silver Standard (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 3 - Preferred Brand — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — ✓ QL
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