ranolazine

1,000 mg, 500 mg — Extended Release Tablet

OXYTOCICS

Also known as: Ranexa Tablet ranolazine tab er 12hr 500 mg, 1000 mg Ranolazine Er 1,000 Mg Tablet Ranolazine Er 500 Mg Tablet ranolazine tb12 500mg, 1000mg ASPRUZYO SPRINKLE Ranolazine ER Oral Tablet Extended Release
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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: 4 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze Tier 2 - Generic — — ✓ QL
Signature Silver Tier 2 - Generic — — ✓ QL
Signature Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold Tier 2 - Generic — — ✓ QL
Streamlined Silver Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 4 hours, 53 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — ✓ 120 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO) 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
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) 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
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via ranolazine tb12 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via ranolazine tb12 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via ranolazine tb12 		Tier 1 - Preferred Generic — — — None
Source: CMS QHP JSON  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Elite Saver Plus Tier 2 - Generic — ✓ — ST
Silver Simple Diabetes Tier 2 - Generic — ✓ — ST
Bronze Classic Standard Tier 2 - Generic — ✓ — ST
Silver Classic Standard Tier 2 - Generic — ✓ — ST
Gold Classic Standard Tier 2 - Generic — ✓ — ST
Bronze Classic Standard | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Classic Standard | with Atrium Health Tier 2 - Generic — ✓ — ST
Gold Classic Standard | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — ✓ — ST
Secure | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Classic | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Simple PCP Saver | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — ✓ — ST
AIAN Cost Share Tier 2 - Generic — ✓ — ST
AIAN Cost Share | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Elite + PCP Saver Plus Tier 2 - Generic — ✓ — ST
Silver Classic Tier 2 - Generic — ✓ — ST
Secure Tier 2 - Generic — ✓ — ST
Bronze Classic 4700 Tier 2 - Generic — ✓ — ST
Silver Simple PCP Saver Tier 2 - Generic — ✓ — ST
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — ✓ — ST
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — ✓ — ST
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — ✓ — ST
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 4 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
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