Savella

Generic: milnacipran hcl

12.5MG, 25MG, 50MG, 100MG — Tablet

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS

Also known as: SAVELLA TABS 12.5MG, 25MG, 50MG, 100MG SAVELLA MIS TITR PAK milnacipran hydrochloride Savella 12.5 Mg Tablet Savella 25 Mg Tablet Savella 50 Mg Tablet Savella 100 Mg Tablet Savella Oral Tablet Milnacipran hydrochloride
GoodRx Compare Prices

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Silver + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Streamlined Silver
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Expanded Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Silver
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Gold
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze 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
Signature Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx 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
Signature Expanded Bronze Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Silver Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Gold Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Silver with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Signature Gold with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via milnacipran HCl 		Tier 1 - Generic — — ✓ QL
BCBS Federal Standard Option 2026
via milnacipran HCl 		Tier 1 - Generic — — ✓ QL
BCBS Federal Focus 2026
via milnacipran HCl 		Tier 1 - Generic — — ✓ QL
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — ✓ QL
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Value 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3600 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver 5000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver 3600 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via milnacipran hydrochloride 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 110 per 365 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 110 per 365 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 110 per 365 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via milnacipran HCl 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 55 per 180 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via milnacipran HCl 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO)
via milnacipran hydrochloride 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via milnacipran HCl 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via milnacipran hydrochloride 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via milnacipran HCl 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via milnacipran hydrochloride 		Tier 2 - Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 110 per 365 days QL
HealthTeam Advantage Plan II (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 110 per 365 days QL
HealthTeam Advantage Vitality Plan (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 110 per 365 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 110 per 365 days QL
Wellcare Simple (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via milnacipran HCl 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via milnacipran hydrochloride 		Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Assist Open (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Giveback Open (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Troy Medicare (HMO)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ — ST
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ ✓ 55 per 180 days ST | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via milnacipran HCl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via milnacipran HCl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via milnacipran HCl 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via milnacipran HCl 		Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 16 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Something not right?