SPS

Generic: sodium polystyrene sulfonate

250 MG — Suspension

Also known as: sps susp 15gm/60ml sodium polystyrene sulfonate Sps Susp 15gm/60ml SPS Oral Suspension Sodium polystyrene sulfonate SPS (Sodium Polystyrene Sulf) Combination Suspension SPS (Sodium Polystyrene Sulf) Rectal Suspension SPS (Sodium Polystyrene Sulf) Multiple Routes Suspension

Compare Prices

Coverage by Insurer

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

Ambetter (Centene)

102 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Elite Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Streamlined Silver via Kionex	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via Kionex	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Signature Gold via Kionex	Tier 2 - Generic	—	—	—	None
Signature Silver via Kionex	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via Kionex	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via Kionex	Tier 2 - Generic	—	—	—	None
Elite Bronze via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Elite Bronze + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Everyday Bronze via Kionex	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold via Kionex	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Streamlined Silver via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Complete Gold	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Everyday Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options	Tier 2 - Generic	—	—	—	None
Complete Gold + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Gold with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Everyday Bronze with Atrium Health via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Gold via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Silver via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Elite Bronze via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Everyday Bronze via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Enhanced Asthma/COPD Care Silver $0 Rx Options via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Complete Gold via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Streamlined Silver	Tier 2 - Generic	—	—	—	None
Streamlined Silver with Atrium Health	Tier 2 - Generic	—	—	—	None
Enhanced CHF Heart Care Silver $0 Rx Options	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Silver + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Everyday Bronze	Tier 2 - Generic	—	—	—	None
Elite Bronze	Tier 2 - Generic	—	—	—	None
Clear Silver with $0 Insulin Options	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze	Tier 2 - Generic	—	—	—	None
Signature Silver	Tier 2 - Generic	—	—	—	None
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Signature Gold	Tier 2 - Generic	—	—	—	None
Signature Gold + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Signature Silver with Atrium Health + Vision + Adult Dental via Kionex	Tier 2 - Generic	—	—	—	None
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	—	None

AmeriHealth Caritas NC

31 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	—	—	None

Blue Cross Blue Shield Federal

9 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026 via Kionex	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Kionex	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via sodium polystyrene sulfonate	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via sodium polystyrene sulfonate	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via sodium polystyrene sulfonate	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Kionex	Tier 1 - Generic	—	—	—	None

Cigna

60 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3600 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Silver via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Bronze via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3600 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Bronze	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Silver	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold RD CMS Standard	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold RD CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 5000 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3600 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Silver CMS Standard via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Bronze via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect myDiabetesCare Silver via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Kionex	Tier 3 - Preferred Brand	—	—	—	None

Medicare Part D

385 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Kionex	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Alignment Health smartHMO (HMO) via Kionex	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health smartHMO (HMO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Kionex	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Kionex	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Kionex	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO)	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO) via Kionex	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Kionex	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum Select (HMO) via Kionex	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO)	Tier 2 - Generic	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Kionex	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Alignment Health AVA (PPO) via sodium polystyrene sulfonate	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Kionex	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Kionex	Tier 2 - Generic	—	—	—	None
Alignment Health Platinum (HMO) via Kionex	Tier 2 - Generic	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Kionex	Tier 2 - Generic	—	—	—	None
HumanaChoice H5216-211 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Assist Open (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Full Access H5525-034 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Assist Open (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Value Plus (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Prime (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Care (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5216-211 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Extra (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Full Access H5525-034 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-049 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-050 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-070 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via sodium polystyrene sulfonate	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Value Plus (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Prime (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Care (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Choice (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Blue Medicare Essential (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Experience Health Medicare Advantage (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5216-211 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Enhanced (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Signature (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Full Access H5525-034 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-049 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-050 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-070 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring True Choice (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Select (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Savings (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthSpring Preferred Plus (HMO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Kionex	Tier 3 - Preferred Brand	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via sodium polystyrene sulfonate	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Kionex	Tier 4 - Non-Preferred	—	—	—	None

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via sodium polystyrene sulfonate	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Kionex	Non-Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026	Tier 2 - Non-Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Tier 2 - Non-Preferred Generic	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic 4700 \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Kionex	Tier 2 - Generic	—	—	—	None
Silver Classic via Kionex	Tier 2 - Generic	—	—	—	None
Secure via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via Kionex	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via Kionex	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via Kionex	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via Kionex	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via Kionex	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via Kionex	Tier 2 - Generic	—	—	—	None

UnitedHealthcare

17 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 21 hours, 42 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) via sodium polystyrene sulfonate	Tier 1 - Preferred Generic	—	—	—	None