tacrolimus

Generic: Prograf

0.5 mg, 1 mg, 5 mg — Capsule

Also known as: tacrolimus oral Protopic Hecoria, Prograf Tacrolimus ER Oral Capsule Extended Release tacrolimus caps .5mg, 1mg, 5mg tacrolimus caps .5mg, 1mg, 5mg; cp24 .5mg, 1mg, 5mg tacrolimus cap 0.5 mg, 1 mg, 5 mg Tacrolimus 0.5 Mg Capsule (Ir) Tacrolimus 1 Mg Capsule (Ir) Tacrolimus 5 Mg Capsule (Ir) tacrolimus soln 5mg/ml Tacrolimus Oral Capsule

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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)

58 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Complete Gold with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Standard Expanded Bronze with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Standard Silver with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Standard Gold with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Complete Gold + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Elite Bronze + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 2 - Generic	✓	—	—	PA
Everyday Bronze	Tier 2 - Generic	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Elite Bronze	Tier 2 - Generic	✓	—	—	PA
Clear Silver with $0 Insulin Options	Tier 2 - Generic	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Complete Gold	Tier 2 - Generic	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Standard Silver + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Standard Gold + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	✓	—	—	PA
Standard Expanded Bronze	Tier 2 - Generic	✓	—	—	PA
Standard Silver	Tier 2 - Generic	✓	—	—	PA
Standard Gold	Tier 2 - Generic	✓	—	—	PA
Everyday Bronze with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Elite Bronze with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Focused Silver with Atrium Health	Tier 2 - Generic	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Silver with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Gold with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Complete Gold with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Focused Silver with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Elite Bronze with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Everyday Bronze with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Gold via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Silver via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Expanded Bronze via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Clear Silver with $0 Insulin Options via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Elite Bronze via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Everyday Bronze via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA
Complete Gold via Prograf	Tier 3 - Preferred Brand	✓	—	—	PA

AmeriHealth Caritas NC

60 plans

Source: CMS QHP JSON · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Envarsus Xr	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Astagraf Xl	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals via Envarsus	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Essential + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals via Astagraf	Tier 5 - Specialty	—	—	—	None

Blue Cross Blue Shield Federal

7 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Prograf	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Envarsus Xr	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Envarsus Xr	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Basic Option 2026 via Prograf	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

15 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Prograf	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Local 2026 via Envarsus Xr	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Value 2026 via Envarsus Xr	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Envarsus Xr	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Value 2026 via Astagraf Xl	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Prograf	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Envarsus Xr	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Astagraf Xl	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Care 2026 via Envarsus Xr	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Astagraf Xl	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Local 2026 via Astagraf Xl	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Care 2026 via Astagraf Xl	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Care 2026 via Prograf	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Value 2026 via Prograf	Tier 3 - High Cost Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Prograf	Tier 3 - High Cost Brand	—	—	—	None

Cigna

40 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 3500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Silver	Tier 2 - Generic	—	—	—	None
Connect myDiabetesCare Bronze	Tier 2 - Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 2 - Generic	—	—	—	None
Connect Gold CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Prograf	Tier 4 - Non-Preferred	—	—	—	None

Medicare Part D

638 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Community Plan (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 100 per 30 days	QL
NHC Advantage (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Community Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Community Plan (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Community Plan (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Longevity Health Plan (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Longevity Health Plan (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	✓ 100 per 30 days	PA \| QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Liberty Medicare Dual Plan (HMO D-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
Liberty Medicare Dual Plan (HMO D-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	✓ 100 per 30 days	QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 100 per 30 days	QL
Liberty Medicare Dual Plan (HMO D-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
PruittHealth Premier (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
PruittHealth Premier (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 100 per 30 days	QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Prograf	Tier 1 - Preferred Generic	✓	—	—	PA
NHC Advantage (HMO I-SNP) via Envarsus Xr	Tier 1 - Preferred Generic	✓	—	—	PA
NHC Advantage (HMO I-SNP) via Envarsus	Tier 1 - Preferred Generic	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	✓	—	ST
Troy Medicare (HMO)	Tier 2 - Generic	—	✓	—	ST
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	✓	—	ST
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	✓ 100 per 30 days	QL
Liberty Medicare Advantage (HMO C-SNP)	Tier 2 - Generic	—	—	✓ 100 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via Envarsus Xr	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Assist Open (PPO) via Envarsus Xr	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Envarsus	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Envarsus Xr	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Assist Open (PPO) via Envarsus	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP) via Envarsus	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Dual Liberty (HMO-POS D-SNP) via Envarsus	Tier 3 - Preferred Brand	✓	—	—	PA
Wellcare Dual Liberty (HMO-POS D-SNP) via Envarsus Xr	Tier 3 - Preferred Brand	✓	—	—	PA
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 60 per 30 days	QL
HealthSpring True Choice (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring True Choice (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring True Choice (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring True Choice (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare Plus (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring TotalCare (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare Plus (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare Plus (HMO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Select (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Savings (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Plus (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring Preferred Select (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring Preferred Savings (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring Preferred Plus (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
HealthSpring Preferred (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Select (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Savings (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Plus (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred (HMO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Select (HMO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Savings (HMO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Plus (HMO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CORE 001 NC (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CORE 001 NC (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 100 per 30 days	PA \| QL
Liberty Medicare Advantage (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Liberty Medicare Advantage (HMO C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Liberty Medicare Advantage (HMO C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple Open (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple Open (PPO)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Simple (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Simple Open (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple Open (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Giveback Open (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Giveback Open (PPO)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Giveback Open (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Giveback Open (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Healthy Blue + Medicare (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Healthy Blue + Medicare (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health NC Duals (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health smartHMO (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum Select (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health AVA (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health smartHMO (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum Select (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health AVA (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health NC Duals (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health smartHMO (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum Select (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health AVA (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan I (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan II (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Vitality Plan (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan I (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan II (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Vitality Plan (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan I (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan II (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Vitality Plan (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan I (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan II (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Vitality Plan (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare (HMO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Assist Open (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Assist Open (PPO)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 100 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Reserve (HMO-POS D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S001 (PPO D-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Signature (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S001 (PPO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Signature (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S001 (PPO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Signature (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
Erickson Advantage Signature (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
Erickson Advantage Freedom (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
Erickson Advantage Liberty (HMO-POS)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S001 (PPO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Signature (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S001 (PPO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Signature (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Astagraf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	✓	—	ST
UHC Complete Care NC-25 (HMO-POS C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf Xl	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-233 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H1036-307 (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-335 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5216-017 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5216-211 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5525-035 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-049 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-050 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-070 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H5525-072 (PPO D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-083 (PPO) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-026 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-057 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-060 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-061 (HMO-POS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Choice H8145-004 (PFFS) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H1036-233 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H1036-335 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice Giveback H5216-017 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice H5216-211 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Full Access H5525-034 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice Giveback H5525-035 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice H5525-049 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice H5525-050 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice H5525-070 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
HumanaChoice H5525-083 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H6622-025 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H6622-026 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H6622-057 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H6622-060 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H6622-061 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Choice H8145-004 (PFFS)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus H1036-137 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-233 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H1036-307 (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-335 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5216-017 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5216-211 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5525-035 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-049 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-050 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-070 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H5525-072 (PPO D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-083 (PPO) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-026 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-057 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-060 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-061 (HMO-POS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Choice H8145-004 (PFFS) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-233 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H1036-307 (HMO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-335 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5216-017 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5216-211 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice Giveback H5525-035 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-049 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-050 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-070 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Dual Select H5525-072 (PPO D-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
HumanaChoice H5525-083 (PPO) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-026 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-057 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-060 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-061 (HMO-POS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Choice H8145-004 (PFFS) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 200 per 30 days	QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Senior Care (HMO I-SNP) via Prograf	Tier 4 - Non-Preferred	✓	—	—	PA
Senior Care (HMO I-SNP) via Envarsus	Tier 4 - Non-Preferred	✓	—	—	PA
Senior Care (HMO I-SNP) via Envarsus Xr	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Prime (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Signature (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CORE 001 NC (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare (HMO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Astagraf	Tier 5 - Specialty	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Blue Medicare Choice (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Blue Medicare Essential (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Healthy Blue + Medicare (HMO-POS D-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health NC Duals (HMO-POS D-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health smartHMO (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health Platinum Select (HMO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
Alignment Health AVA (PPO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
HealthTeam Advantage Plan I (PPO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
HealthTeam Advantage Plan II (PPO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA
HealthTeam Advantage Vitality Plan (PPO) via Envarsus Xr	Tier 5 - Specialty	✓	—	—	PA

NC Medicaid PDL

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Astagraf Xl	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Envarsus Xr	Preferred	—	—	—	None

NC State Health Plan

6 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Prograf	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Prograf	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Prograf	Tier 3 - Non-Preferred Brand	—	—	—	None

Oscar Health

56 plans

Source: CMS QHP JSON · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Gold Classic Standard	Tier 2 - Generic	—	—	—	None
Silver Classic Standard	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health	Tier 2 - Generic	—	—	—	None
AIAN Cost Share	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700	Tier 2 - Generic	—	—	—	None
Secure	Tier 2 - Generic	—	—	—	None
Silver Classic	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AIAN Cost Share via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Gold Elite Saver Plus via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Secure \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
AIAN Cost Share \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard \| with Atrium Health via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Secure via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 via Prograf	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver via Prograf	Tier 4 - Non-Preferred	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None

UnitedHealthcare

13 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 17 hours, 39 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Bronze Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL
UHC Gold Standard (No Referrals)	Tier 3 - Preferred Brand	—	—	✓	QL