sulfasalazine
500 MG — Tablet
Also known as:
sulfasalazine oral
sulfasalazine tabs 500mg; tbec 500mg
sulfasalazine tab delayed release 500 mg
sulfasalazine tab 500 mg
Sulfasalazine 500 Mg Tablet
Sulfasalazine Dr 500 Mg Tablet
AZULFIDINE
SULFASALAZINE DR
sulfaSALAzine Oral Tablet
sulfaSALAzine Oral Tablet Delayed Release
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Streamlined Silver | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | 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 | Tier 2 - Generic | — | — | — | None |
| Signature Silver | Tier 2 - Generic | — | — | — | None |
| Signature Gold | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
7 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 Basic Option 2026
via Azulfidine En-Tabs |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Azulfidine En-Tabs |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Azulfidine |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Azulfidine |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Advantage 2026
via Azulfidine |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Value 2026
via Azulfidine |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Azulfidine |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Local 2026
via Azulfidine |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Care 2026
via Azulfidine |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Azulfidine En-Tabs |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Azulfidine En-Tabs |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Value 2026
via Azulfidine En-Tabs |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Care 2026
via Azulfidine En-Tabs |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
|
BCBSNC Blue Local 2026
via Azulfidine En-Tabs |
Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Cigna
40 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 5000 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 3500 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 6000 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 5000 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold 1500 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Silver
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Bronze
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
|
Connect Silver CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3000 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3600 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 5000 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 5500 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 6500 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3600 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold RD CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 2200 Indiv Med Deductible
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD CMS Standard
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
Medicare Part D
280 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Longevity Health Plan (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
PruittHealth Premier (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Dual Plan (HMO D-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
NHC Advantage (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via SULFASALAZINE DR |
Tier 1 - Preferred Generic | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HealthSpring Preferred (HMO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HealthSpring Preferred Select (HMO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring Preferred Plus (HMO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Senior Care (HMO I-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Troy Medicare (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice Giveback H5216-017 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice H5216-211 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health Platinum (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health smartHMO (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health Platinum Select (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Enhanced (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Enhanced (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature Extra (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature Giveback (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Full Access H5525-034 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice Giveback H5525-035 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice H5525-049 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice H5525-050 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice H5525-070 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HumanaChoice H5525-083 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Signature (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Freedom (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Liberty (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Liberty Medicare Advantage (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H6622-025 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H6622-026 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H6622-057 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H6622-060 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H6622-061 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Alignment Health AVA (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring True Choice (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Choice H8145-004 (PFFS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring TotalCare (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring Preferred (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring Preferred Select (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring Preferred Savings (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring Preferred Plus (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthTeam Advantage Plan I (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthTeam Advantage Plan II (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthTeam Advantage Vitality Plan (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H1036-137 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H1036-233 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Humana Gold Plus H1036-335 (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Simple Open (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Assist Open (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Giveback Open (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Dual (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Value Plus (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Prime (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature Care (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Enhanced (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare PPO Enhanced (PPO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare Essential Plus (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare Enhanced (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare Choice (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Blue Medicare Essential (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Experience Health Medicare Advantage (HMO)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Simple (HMO-POS)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Access (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via SULFASALAZINE DR |
Tier 2 - Generic | — | — | — | None |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE 005 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE 008 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED GIVEBACK 012 NC (HMO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE 001 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED GIVEBACK 002 NC (HMO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CORE 001 NC (HMO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED CHOICE 003 NC (PPO)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via SULFASALAZINE DR |
Tier 3 - Preferred Brand | — | — | — | None |
NC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Azulfidine |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Azulfidine |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via Azulfidine |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Secure | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | Tier 2 - Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
TRICARE
1 planUnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | 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) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |