Rybelsus

Generic: semaglutide

1.5MG, 3MG, 4MG, 7MG, 9MG, 14MG — Tablet

Also known as: RYBELSUS TABS 1.5MG, 3MG, 4MG, 7MG, 9MG, 14MG semaglutide Rybelsus 1.5 Mg Tablet Rybelsus 3 Mg Tablet Rybelsus 4 Mg Tablet Rybelsus 7 Mg Tablet Rybelsus 9 Mg Tablet Rybelsus 14 Mg Tablet RYBELSUS TABS 3MG, 7MG, 14MG Rybelsus Oral Tablet

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

58 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Silver via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Gold with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Silver with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Complete Gold with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Focused Silver with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Elite Bronze via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Standard Expanded Bronze via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL

AmeriHealth Caritas NC

20 plans

Source: CMS QHP JSON · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Signature + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Signature + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Essential + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Gold Signature + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Essential + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Premier + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Premier + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Premier + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Signature + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Gold Premier + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Signature + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Essential + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Essential + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Gold Signature + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Premier + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Brand-Preferred	✓	—	✓	PA \| QL

Blue Cross Blue Shield Federal

5 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Focus 2026	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026 via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026 via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Non-Preferred Brand	✓	—	—	PA

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Value 2026	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Local 2026	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Advantage 2026	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Value 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Care 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Local 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Advantage 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL
BCBSNC Blue Care 2026	Tier 3 - High Cost Brand	✓	—	✓ Restricted Access	PA \| QL

Cigna

40 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3000 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver 3000 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 6500 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold RD CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze CMS Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver 4400 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD 6000 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 6500 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 5000 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver 4400 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 7000 HSA Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 3500 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD 5000 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver 3500 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD 6000 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 5500 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect myDiabetesCare Bronze via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold 1500 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 2200 Indiv Med Deductible via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect myDiabetesCare Silver via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze 5500 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect myDiabetesCare Bronze	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold 1500 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Silver RD 2200 Indiv Med Deductible	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect myDiabetesCare Silver	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold RD CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Bronze RD CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Connect Gold CMS Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL

Medicare Part D

283 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 10 hours, 9 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 Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
NHC Advantage (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 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)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 per 30 days	PA \| QL
PruittHealth Premier (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 30 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) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 1 - Preferred Generic	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Simple Open (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Simple (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Simple Open (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Simple (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Giveback Open (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Giveback Open (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare PPO Enhanced (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Blue Medicare Essential Plus (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Blue Medicare Enhanced (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Blue Medicare Choice (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Blue Medicare Essential (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Experience Health Medicare Advantage (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Healthy Blue + Medicare (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Blue Medicare PPO Enhanced (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Essential Plus (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Enhanced (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Choice (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Blue Medicare Essential (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Experience Health Medicare Advantage (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Platinum (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health NC Duals (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health smartHMO (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health Platinum Select (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health AVA (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Alignment Health Platinum (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health smartHMO (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Platinum Select (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Alignment Health AVA (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Plan I (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthTeam Advantage Plan II (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthTeam Advantage Vitality Plan (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthTeam Advantage Plan I (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Plan II (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthTeam Advantage Vitality Plan (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Troy Medicare (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Troy Medicare (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Liberty Open (PPO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Assist Open (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Dual Access (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Assist Open (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Erickson Advantage Signature (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Erickson Advantage Freedom (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Erickson Advantage Liberty (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Signature (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Freedom (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Liberty (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Erickson Advantage Champion (HMO-POS C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Value Plus (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Prime (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature Care (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Enhanced (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Enhanced (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature Extra (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature Giveback (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Value Plus (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Prime (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Care (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Extra (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature Giveback (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring True Choice (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring True Choice (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring TotalCare (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring TotalCare Plus (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring TotalCare (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring Preferred Select (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring Preferred Savings (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring Preferred Plus (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HealthSpring Preferred (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Select (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Savings (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HealthSpring Preferred Plus (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CORE 001 NC (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CORE 001 NC (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H1036-137 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H1036-233 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Dual Select H1036-307 (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H1036-335 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice Giveback H5216-017 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice H5216-211 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Full Access H5525-034 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice Giveback H5525-035 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice H5525-049 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice H5525-050 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice H5525-070 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Dual Select H5525-072 (PPO D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
HumanaChoice H5525-083 (PPO) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H6622-025 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H6622-026 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H6622-057 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H6622-060 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H6622-061 (HMO-POS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Choice H8145-004 (PFFS) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus H1036-137 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H1036-233 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H1036-335 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice Giveback H5216-017 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5216-211 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Full Access H5525-034 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice Giveback H5525-035 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-049 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-050 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-070 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Choice H8145-004 (PFFS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
HumanaChoice H5525-083 (PPO)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-025 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-026 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-057 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-060 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus H6622-061 (HMO-POS)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Senior Care (HMO I-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓ 3 per 28 days	PA \| QL
Senior Care (HMO I-SNP)	Tier 3 - Preferred Brand	✓	—	✓ 30 per 30 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 5 - Specialty	✓	—	✓ 2 per 28 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 5 - Specialty	✓	—	✓ 2 per 28 days	PA \| QL
Troy Medicare (HMO) via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 5 - Specialty	✓	—	✓ 2 per 28 days	PA \| QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 6 - Specialty Plus	✓	—	✓ 3 per 28 days	PA \| QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 6 - Specialty Plus	✓	—	✓ 30 per 30 days	PA \| QL

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Wegovy Wegovy is the same molecule (semaglutide) but is indicated for weight management, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	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: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026	Tier 2 - Non-Preferred Generic	✓	—	✓	PA \| QL
NC State Health Plan - 80/20 Plus PPO 2026	Tier 2 - Non-Preferred Generic	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026	Tier 2 - Non-Preferred Generic	✓	—	✓	PA \| QL

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic Standard \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Diabetes \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
AIAN Cost Share via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Chronic Care CKM \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Diabetes \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700 via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic Standard via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700 \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure \| with Atrium Health via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Classic Standard \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Classic	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple PCP Saver	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Gold Elite Saver Plus	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Silver Simple Diabetes	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Secure \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Classic 4700 \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via semaglutide	Tier 3 - Non-Formulary	✓	—	—	PA

UnitedHealthcare

26 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 10 hours, 9 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Standard+ Dental + Vision (No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Standard (No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Standard (No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Standard (No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Standard (No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Standard (No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Standard (No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Ozempic Ozempic is the same molecule (semaglutide) but is indicated for type 2 diabetes, while Rybelsus is for type 2 diabetes (oral). Coverage may differ by indication.	Tier 3 - Preferred Brand	✓	—	✓	PA \| QL