Sernivo

Generic: betamethasone dipropionate

0.05 % — Spray

CORTICOSTEROIDS-IMMUNE MODULATORS

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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: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Attero 		Tier 2 - Generic — ✓ — ST
Enhanced Asthma/COPD Care Silver $0 Rx Options
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Everyday Bronze
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Elite Bronze
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Clear Silver with $0 Insulin Options
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Silver
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Gold
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Everyday Bronze with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Elite Bronze with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Focused Silver with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Complete Gold with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Silver with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Gold with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Complete Gold + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Everyday Bronze + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Elite Bronze + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Everyday Bronze with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Elite Bronze with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Focused Silver with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Complete Gold with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Silver + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Gold + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Silver with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Signature Gold with Atrium Health + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Gold with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Silver with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Complete Gold with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Focused Silver with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Elite Bronze with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Everyday Bronze with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Gold
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Silver
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze
via Attero 		Tier 2 - Generic — ✓ — ST
Clear Silver with $0 Insulin Options
via Attero 		Tier 2 - Generic — ✓ — ST
Elite Bronze
via Attero 		Tier 2 - Generic — ✓ — ST
Everyday Bronze
via Attero 		Tier 2 - Generic — ✓ — ST
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Complete Gold
via Attero 		Tier 2 - Generic — ✓ — ST
Complete Gold
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Enhanced CHF Heart Care Silver $0 Rx Options
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Streamlined Silver with Atrium Health
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Streamlined Silver
via betamethasone dipropionate 		Tier 2 - Generic — ✓ — ST
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Streamlined Silver
via Attero 		Tier 2 - Generic — ✓ — ST
Streamlined Silver with Atrium Health
via Attero 		Tier 2 - Generic — ✓ — ST
Enhanced CHF Heart Care Silver $0 Rx Options
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Gold with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Silver with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Gold + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Silver + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Signature Expanded Bronze + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Complete Gold with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Focused Silver with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Elite Bronze with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Elite Bronze + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Everyday Bronze + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Complete Gold + Vision + Adult Dental
via Attero 		Tier 2 - Generic — ✓ — ST
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Premier + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via betamethasone dipropionate 		Tier 4 - Non-Preferred — ✓ — ST
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via Enstilar 		Tier 3 - Non-Preferred Brand — — ✓ QL
BCBS Federal Standard Option 2026
via Enstilar 		Tier 3 - Non-Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via betamethasone dipropionate 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via betamethasone dipropionate 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via betamethasone dipropionate 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via betamethasone dipropionate 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via betamethasone dipropionate 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via Enstilar 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026
via Enstilar 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026
via Enstilar 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Value 2026
via Enstilar 		Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026
via Enstilar 		Tier 3 - High Cost Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED CHOICE 003 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Enstilar 		Tier 5 - Specialty ✓ — ✓ 120 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Enstilar 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Enstilar 		Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026
via Enstilar 		Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via Enstilar 		Tier 2 - Non-Preferred Generic ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
69803NC0010113
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010114
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010115
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010116
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010117
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010075
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010074
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Classic 4700
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Secure
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Classic
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010108
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010110
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010111
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010112
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010076
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010077
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010078
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010079
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010080
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010081
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010082
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010083
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010084
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010085
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Core Plan
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Core Plan | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes with Adult Dental & Vision
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
69803NC0010109
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Simple Diabetes | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple PCP Saver | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Simple Diabetes | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Classic | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Classic 4700 | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Secure | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Gold Classic Standard | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Classic Standard | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Classic Standard | with Atrium Health
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Gold Classic Standard
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Silver Classic Standard
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Bronze Classic Standard
via betamethasone dipropionate 		Tier 3 - Preferred Brand — — — None
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary — — — None
TRICARE Uniform Formulary 2026
via Enstilar 		Tier 3 - Non-Formulary ✓ — — PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 7 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via betamethasone dipropionate 		Tier 4 - Non-Preferred — — ✓ QL
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