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
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Expanded Bronze + 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
Focused Silver 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
Everyday Bronze with Atrium Health + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Gold with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Silver with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Gold
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Silver
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Standard Expanded Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Everyday Bronze
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via milnacipran hydrochloride 		Tier 2 - Generic ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold 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
Elite Bronze with Atrium Health + Vision + Adult Dental 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
Standard Gold with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Silver with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health 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
Standard Gold Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health 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 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
Source: CMS QHP JSON  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Signature + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + 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 Silver Essential + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via milnacipran HCl 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + 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 Bronze Essential + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Savella Titration Pack 		Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 20 hours, 12 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 Focus 2026
via milnacipran HCl 		Tier 1 - Generic — — ✓ QL
BCBS Federal Standard Option 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: Jul 1, 2026  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Value 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Care 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Local 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Advantage 2026
via Savella Titration Pa 		Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — ✓ Restricted Access QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver
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 1500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze
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 Bronze RD 6000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver 3500 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 Silver RD 3500 Indiv Med Deductible
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
Connect Silver 4400 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 Bronze 6500 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Connect Silver RD 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 Bronze RD CMS Standard
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 CMS Standard
via Savella Titration Pack 		Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 20 hours, 12 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
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 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 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) 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 Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 55 per 180 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Savella Titration Pack 		Tier 1 - Preferred Generic — — ✓ 110 per 365 days QL
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
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS) 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-0016 (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-0001 (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
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
UHC Dual Complete NC-S001 (PPO D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
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 Guardian (HMO-POS I-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
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
AARP Medicare Advantage from UHC NC-24 (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
UHC Dual Complete NC-D001 (HMO-POS D-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-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
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-0015 (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 Giveback from UHC NC-14 (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 from UHC NC-0012 (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-0009 (HMO-POS)
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
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
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
Wellcare Simple Open (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Simple (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Giveback Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
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
HealthTeam Advantage Plan I (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 Vitality Plan (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 110 per 365 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 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 Dual Access (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
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — ✓ 55 per 180 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Savella Titration Pack 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
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
Erickson Advantage Champion (HMO-POS C-SNP) 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
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (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
UHC Complete Care NC-27 (HMO-POS C-SNP)
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) 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
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
Troy Medicare (HMO)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — ✓ ✓ 60 per 30 days ST | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ ✓ 55 per 180 days ST | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — ✓ — ST
Troy Medicare (HMO) Tier 4 - Non-Preferred — ✓ — ST
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Savella Titration Pack 		Tier 4 - Non-Preferred — ✓ — ST
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 20 hours, 12 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 - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AIAN Cost Share | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | 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
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | 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
Silver Simple Diabetes Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 20 hours, 12 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: Jun 23, 2026  ·  Checked: 20 hours, 12 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard (No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value + ($0 Virtual Urgent Care, 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 Silver Value ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Standard (No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard (No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Standard (No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard (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 Silver Value + ($0 Virtual Urgent Care, 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 Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via milnacipran hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Standard (No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, 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 Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 4 - Non-Preferred — ✓ ✓ ST | QL
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