Synjardy

Generic: empagliflozin

12.5-500 Mg — Tablet

Also known as: SYNJARDY TAB SYNJARDY TAB 5-500MG SYNJARDY TAB 5-1000MG SYNJARDY TAB 12.5-500 empagliflozin Synjardy 12.5-500 Mg Tablet Synjardy 5-500 Mg Tablet

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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)

116 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Clear Silver with $0 Insulin Options via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold via Glyxambi	Tier 3 - Preferred Brand	—	—	✓	QL
Clear Silver with $0 Insulin Options via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze	Tier 3 - Preferred Brand	—	—	✓	QL
Clear Silver with $0 Insulin Options	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Clear Silver with $0 Insulin Options via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental via Trijardy	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Elite Bronze with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Focused Silver with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Standard Silver with Atrium Health via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Complete Gold + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental via Jardiance	Tier 3 - Preferred Brand	—	—	✓	QL

Blue Cross Blue Shield Federal

9 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Focus 2026 via Jardiance	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Standard Option 2026 via Glyxambi	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Standard Option 2026	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Standard Option 2026 via Jardiance	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Basic Option 2026 via Glyxambi	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Basic Option 2026 via Jardiance	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Focus 2026 via Glyxambi	Tier 2 - Preferred Brand	—	✓	—	ST
BCBS Federal Focus 2026	Tier 2 - Preferred Brand	—	✓	—	ST

Blue Cross Blue Shield of NC

15 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Care 2026	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Value 2026	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Advantage 2026 via Glyxambi	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Glyxambi	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Local 2026 via Glyxambi	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Care 2026 via Glyxambi	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Advantage 2026 via Jardiance	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026 via Jardiance	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Local 2026 via Jardiance	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Care 2026 via Jardiance	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Value 2026 via Jardiance	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Advantage 2026	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Local 2026	Tier 3 - High Cost Brand	—	—	✓	QL
BCBSNC Blue Value 2026 via Glyxambi	Tier 3 - High Cost Brand	—	—	✓	QL

Cigna

2 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026	Tier 2 - Preferred Brand	—	—	✓	QL
Cigna Plus NC 4-Tier Formulary 2026 via Jardiance	Tier 2 - Preferred Brand	—	—	✓	QL

Medicare Part D

488 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP)	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
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Longevity Health Plan (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Longevity Health Plan (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Longevity Health Plan (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
NHC Advantage (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
NHC Advantage (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
NHC Advantage (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
PruittHealth Premier (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
PruittHealth Premier (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
PruittHealth Premier (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP) via Jardiance	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP) via Trijardy	Tier 1 - Preferred Generic	—	—	✓ 60 per 30 days	QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Glyxambi	Tier 1 - Preferred Generic	—	—	—	None
Aetna Medicare Signature (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HealthSpring True Choice (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring TotalCare (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring TotalCare Plus (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred Select (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred Savings (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred Plus (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CORE 001 NC (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CORE 001 NC (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CORE 001 NC (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple Open (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple Open (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Simple Open (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Simple (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Giveback Open (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Giveback Open (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare PPO Enhanced (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Blue Medicare Enhanced (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Blue Medicare Choice (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Experience Health Medicare Advantage (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Blue Medicare Enhanced (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare Choice (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare Essential (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Experience Health Medicare Advantage (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare PPO Enhanced (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health Platinum (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health NC Duals (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health smartHMO (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum Select (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health AVA (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health smartHMO (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health Platinum Select (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health AVA (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Alignment Health Platinum (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health NC Duals (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health smartHMO (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum Select (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health AVA (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Senior Care (HMO I-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Signature (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Freedom (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Signature (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Freedom (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Liberty (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Signature (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Freedom (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AARP Medicare Advantage from UHC NC-0016 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0017 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Signature (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Guardian (HMO-POS I-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Freedom (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Liberty (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S001 (PPO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Dual Complete NC-S2 (PPO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0001 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0004 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
UHC Complete Care NC-25 (HMO-POS C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-27 (HMO-POS C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
UHC Complete Care NC-28 (HMO-POS C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Erickson Advantage Champion (HMO-POS C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Value Plus (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Value Plus (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Value Plus (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Prime (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Care (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5216-211 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Full Access H5525-034 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice Giveback H5525-035 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-049 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-050 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-070 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H5525-072 (PPO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-083 (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-026 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Senior Care (HMO I-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Senior Care (HMO I-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Senior Care (HMO I-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Plan I (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Plan II (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Vitality Plan (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
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
HealthTeam Advantage Plan I (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	—	None
Troy Medicare (HMO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Troy Medicare (HMO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Troy Medicare (HMO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Troy Medicare (HMO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Assist Open (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Assist Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Assist Open (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Assist Open (PPO) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-137 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-233 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5216-211 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Full Access H5525-034 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice Giveback H5525-035 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-049 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-050 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-070 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H5525-072 (PPO D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-083 (PPO) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-026 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS) via Jardiance	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-137 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-233 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice Giveback H5216-017 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5216-211 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Full Access H5525-034 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice Giveback H5525-035 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-049 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-050 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-070 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
HumanaChoice H5525-083 (PPO)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-026 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-057 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-060 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H6622-061 (HMO-POS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS)	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-137 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-233 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice Giveback H5216-017 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5216-211 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Full Access H5525-034 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice Giveback H5525-035 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-049 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-050 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-070 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H5525-072 (PPO D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HumanaChoice H5525-083 (PPO) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-026 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-057 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-060 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H6622-061 (HMO-POS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS) via Glyxambi	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Humana Gold Plus H1036-137 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus H1036-233 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Dual Select H1036-307 (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Trijardy	Tier 3 - Preferred Brand	—	—	✓ 60 per 30 days	QL
Blue Medicare Essential (HMO) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Choice (HMO) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Essential Plus (HMO-POS) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Experience Health Medicare Advantage (HMO) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare PPO Enhanced (PPO) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Healthy Blue + Medicare (HMO-POS D-SNP) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Blue Medicare Enhanced (HMO-POS) via Glyxambi	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Jardiance	Tier 6 - Specialty Plus	—	—	✓ 30 per 30 days	QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Glyxambi	Tier 6 - Specialty Plus	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Trijardy	Tier 6 - Specialty Plus	—	—	—	None

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Jardiance	Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Glyxambi	Non-Preferred	—	—	—	None

NC State Health Plan

9 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 6 hours, 4 minutes ago

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

UnitedHealthcare

2 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 6 hours, 4 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UnitedHealthcare NC Individual & Family 2026 via Jardiance	Unknown	—	—	✓	QL
UnitedHealthcare NC Individual & Family 2026	Unknown	—	—	✓	QL