Renacidin Irrigation

Generic: Citric Acid

Solution

Calculi Dissolution Agent

Also known as: RENACIDIN SOL Renacidin Irrigation Solution RENACIDIN IRRIGATION SOLUTION Citric Acid
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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, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via Phexxi 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Silver
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Gold
via Phexxi 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Silver
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Gold
via Phexx 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via Phexx 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via Phexxi 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Phexx 		Tier 0 - $0 Preventive — — — None
Complete Gold
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Phexxi 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Phexxi 		Tier 0 - $0 Preventive — — — None
Complete Gold
via Phexxi 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via Phexx 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via Phexx 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Standard Gold
via citric acid 		Tier 2 - Generic — — — None
Standard Silver
via citric acid 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via citric acid 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Complete Gold
via citric acid 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via citric acid 		Tier 2 - Generic — — — None
Everyday Bronze
via citric acid 		Tier 2 - Generic — — — None
Elite Bronze
via citric acid 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via citric acid 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Complete Gold
via Cytra 2 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Cytra 2 		Tier 2 - Generic — — — None
Everyday Bronze
via Cytra 2 		Tier 2 - Generic — — — None
Elite Bronze
via Cytra 2 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via Cytra 2 		Tier 2 - Generic — — — None
Standard Expanded Bronze
via Cytra 2 		Tier 2 - Generic — — — None
Standard Silver
via Cytra 2 		Tier 2 - Generic — — — None
Standard Gold
via Cytra 2 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Cytra 2 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via citric acid 		Tier 2 - Generic — — — None
Standard Gold with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Standard Silver with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via citric acid 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via Cytra 2 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Phexxi 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Phexx 		Brand-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Clenpiq 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Clenpiq 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Phexx 		Tier A - ACA $0 Copay — — — None
BCBSNC Blue Care 2026
via Phexx 		Tier A - ACA $0 Copay — — — None
BCBSNC Blue Value 2026
via Phexx 		Tier A - ACA $0 Copay — — — None
BCBSNC Blue Advantage 2026
via Phexx 		Tier A - ACA $0 Copay — — — None
BCBSNC Blue Local 2026
via Phexx 		Tier A - ACA $0 Copay — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 3500 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Silver
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Bronze
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Phexxi 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Silver
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Bronze
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver 3500 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver 4400 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Phexx 		Tier 1 - Preferred Generic — — — None
Connect Silver RD CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Phexx 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Phexxi 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard
via Oracit 		Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Clenpiq 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Clenpiq 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Clenpiq 		Tier 1 - Preferred Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Clenpiq 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Clenpiq 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - HDHP 2026
via Clenpiq 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Phexx 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - HDHP 2026
via Phexx 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Phexx 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Clenpiq 		Tier 0 - $0 Copay (ACA Preventive) — — — None
NC State Health Plan - HDHP 2026
via Oracit 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Oracit 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Oracit 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic Standard | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic Standard | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Gold Classic Standard
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic Standard
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic Standard
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Elite + PCP Saver Plus
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Secure
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Secure | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Diabetes
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Classic 4700
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple PCP Saver
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Gold Elite Saver Plus
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Simple Diabetes | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
AIAN Cost Share
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
AIAN Cost Share | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Gold Classic Standard | with Atrium Health
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
Silver Classic
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Secure | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Classic | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Diabetes | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard | with Atrium Health
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Secure
via Clenpiq 		Tier 3 - Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 18 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Standard (No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Standard (No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Standard (No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Standard (No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Standard (No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Standard (No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Phexxi 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Phexx 		Tier 0 - $0 Preventive — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Silver Standard (No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Gold Standard (No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Clenpiq 		Tier 4 - Non-Preferred — — — None
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