Rinvoq

Generic: upadacitinib

15MG, 30MG, 45MG — Extended Release Tablet

Also known as: upadacitinib Rinvoq Er 15 Mg Tablet Rinvoq Er 30 Mg Tablet Rinvoq Er 45 Mg Tablet RINVOQ TB24 15MG, 30MG, 45MG Rinvoq Oral Tablet Extended Release

Compare Prices

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

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Expanded Bronze	Tier 5 - Specialty	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options	Tier 5 - Specialty	✓	—	✓	PA \| QL
Elite Bronze	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Silver with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Gold with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Complete Gold with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Focused Silver with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Gold	Tier 5 - Specialty	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Complete Gold	Tier 5 - Specialty	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 5 - Specialty	✓	—	✓	PA \| QL
Everyday Bronze	Tier 5 - Specialty	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Expanded Bronze + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Silver + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Gold + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 5 - Specialty	✓	—	✓	PA \| QL
Standard Silver	Tier 5 - Specialty	✓	—	✓	PA \| QL

AmeriHealth Caritas NC

20 plans

Source: CMS QHP JSON · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Rinvoq Lq	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals	Tier 5 - Specialty	✓	—	—	PA

Blue Cross Blue Shield Federal

4 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Standard Option 2026	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Standard Option 2026 via Rinvoq Lq	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Basic Option 2026 via Rinvoq Lq	Tier 4 - Preferred Specialty	✓	—	—	PA

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Care 2026 via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Value 2026 via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Local 2026	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Advantage 2026	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Care 2026	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Value 2026	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Advantage 2026 via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ Restricted Access; Limited Distribution	PA \| QL

Cigna

20 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect myDiabetesCare Silver via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Gold CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver RD CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze 6500 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver 3000 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver RD 5000 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver 4400 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze 7000 HSA Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver RD 3500 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze RD 5000 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver 3500 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze RD 6000 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze 5500 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect myDiabetesCare Bronze via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Gold 1500 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Silver RD 2200 Indiv Med Deductible via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Gold RD CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL
Connect Bronze RD CMS Standard via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓	PA \| QL

Medicare Part D

274 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Longevity Health Plan (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
NHC Advantage (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Liberty Medicare Dual Plan (HMO D-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
PruittHealth Premier (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Rinvoq Lq	Tier 1 - Preferred Generic	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring True Choice (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring True Choice (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring TotalCare (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring TotalCare (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring TotalCare Plus (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring Preferred (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Select (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Savings (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Plus (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring Preferred Select (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring Preferred Savings (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthSpring Preferred Plus (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CORE 001 NC (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CORE 001 NC (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Simple Open (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Simple (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Simple Open (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Simple (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Giveback Open (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Giveback Open (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Blue Medicare PPO Enhanced (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Essential Plus (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Enhanced (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Choice (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Essential (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Experience Health Medicare Advantage (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare PPO Enhanced (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Blue Medicare Essential Plus (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Blue Medicare Enhanced (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Blue Medicare Choice (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Blue Medicare Essential (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Experience Health Medicare Advantage (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Healthy Blue + Medicare (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health Platinum (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health smartHMO (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Platinum Select (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health AVA (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Platinum (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health NC Duals (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health smartHMO (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health Platinum Select (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Alignment Health AVA (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthTeam Advantage Plan I (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Plan II (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Vitality Plan (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Plan I (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthTeam Advantage Plan II (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthTeam Advantage Vitality Plan (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Assist Open (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Liberty Open (PPO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Assist Open (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Dual Access (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H6622-025 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Signature (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Freedom (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Liberty (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Erickson Advantage Signature (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Erickson Advantage Freedom (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Erickson Advantage Liberty (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Erickson Advantage Champion (HMO-POS C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Value Plus (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Prime (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Care (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (HMO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Extra (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Giveback (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Value Plus (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Prime (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature Care (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Enhanced (HMO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature Extra (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature Giveback (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Signature (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H1036-335 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice Giveback H5216-017 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5216-211 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Full Access H5525-034 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice Giveback H5525-035 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-049 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-050 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-070 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-083 (PPO)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-025 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-026 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-057 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-060 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-061 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Choice H8145-004 (PFFS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H1036-137 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H1036-233 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Dual Select H1036-307 (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H1036-335 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice Giveback H5216-017 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice H5216-211 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Full Access H5525-034 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice Giveback H5525-035 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice H5525-049 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice H5525-050 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice H5525-070 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Dual Select H5525-072 (PPO D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
HumanaChoice H5525-083 (PPO) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-026 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H6622-057 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H6622-060 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H6622-061 (HMO-POS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Choice H8145-004 (PFFS) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Senior Care (HMO I-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Senior Care (HMO I-SNP) via Rinvoq Lq	Tier 5 - Specialty	✓	—	✓ 360 per 30 days	PA \| QL
Humana Gold Plus H1036-137 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H1036-233 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 5 - Specialty	✓	—	✓ 30 per 30 days	PA \| QL

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Rinvoq Lq	Non-Preferred	✓	✓	—	PA \| ST
NC Medicaid Preferred Drug List 2026	Non-Preferred	✓	✓	—	PA \| ST

NC State Health Plan

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Rinvoq Lq	Tier 5 - Preferred Brand Specialty	✓	—	✓ Preferred for	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026 via Rinvoq Lq	Tier 5 - Preferred Brand Specialty	✓	—	✓ Preferred for	PA \| QL
NC State Health Plan - HDHP 2026 via Rinvoq Lq	Tier 5 - Preferred Brand Specialty	✓	—	✓ Preferred for	PA \| QL

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Simple Diabetes \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
AIAN Cost Share	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple Diabetes	Tier 5 - Specialty	✓	—	✓	PA \| QL
Gold Elite Saver Plus	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple PCP Saver	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Classic 4700	Tier 5 - Specialty	✓	—	✓	PA \| QL
Secure	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Classic	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus	Tier 5 - Specialty	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Classic Standard \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Gold Classic Standard	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Classic Standard	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Classic Standard	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Bronze Classic 4700 \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL
Secure \| with Atrium Health	Tier 5 - Specialty	✓	—	✓	PA \| QL

UnitedHealthcare

13 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 12 hours, 34 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Bronze Standard (No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Silver Standard (No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Gold Standard (No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 5 - Specialty	✓	—	✓	PA \| QL