Symdeko (50 MG / 75 MG; 75 MG)

Generic: ivacaftor

75 MG — Tablet

Cystic Fibrosis Transmembrane Conductance Regulator Potentiator

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Silver + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Silver with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Standard Gold with Atrium Health
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via ORKAMBI 		Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Standard Option 2026
via ORKAMBI 		Tier 4 - Preferred Specialty ✓ — — PA
BCBS Federal Basic Option 2026
via ORKAMBI 		Tier 4 - Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Advantage 2026
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Local 2026
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Local 2026
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Value 2026
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Care 2026
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Care 2026
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
BCBSNC Blue Value 2026
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ Limited Distribution PA | QL
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
NHC Advantage (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
NHC Advantage (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
NHC Advantage (HMO I-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 112 per 28 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 112 per 28 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 112 per 28 days PA | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Longevity Health Plan (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Longevity Health Plan (HMO I-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Longevity Health Plan (HMO I-SNP)
via ORKAMBI 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Kalydeco 		Tier 1 - Preferred Generic ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring True Choice (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring True Choice (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring True Choice (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring True Choice (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Select (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Savings (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Plus (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Select (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Savings (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Plus (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Select (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Savings (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Plus (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Select (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Savings (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthSpring Preferred Plus (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Blue Medicare PPO Enhanced (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Choice (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Experience Health Medicare Advantage (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Choice (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Experience Health Medicare Advantage (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum (HMO) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health smartHMO (HMO) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum Select (HMO) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health AVA (PPO) Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health smartHMO (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum Select (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health AVA (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health smartHMO (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum Select (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health AVA (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health smartHMO (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum Select (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
Alignment Health AVA (PPO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 60 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthTeam Advantage Plan II (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthTeam Advantage Plan I (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 112 per 28 days PA | QL
HealthTeam Advantage Plan II (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 112 per 28 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 112 per 28 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 112 per 28 days PA | QL
Troy Medicare (HMO) Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — — PA
Troy Medicare (HMO)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Senior Care (HMO I-SNP)
via Symdeko (100 MG / 150 MG; 150 MG) 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Signature (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Signature (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Freedom (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Liberty (HMO-POS)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Value Plus (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Value Plus (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Prime (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Care (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (HMO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Prime (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Care (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (HMO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Enhanced (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Extra (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Aetna Medicare Signature (PPO)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Senior Care (HMO I-SNP) Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Senior Care (HMO I-SNP)
via ORKAMBI 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Senior Care (HMO I-SNP)
via Kalydeco 		Tier 5 - Specialty ✓ — ✓ 56 per 28 days PA | QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via ORKAMBI 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via ORKAMBI 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via ORKAMBI 		Tier 6 - Non-Preferred Brand Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via ORKAMBI 		Unknown ✓ — ✓ PA | QL
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