tofacitinib

11 MG — Tablet

Janus Kinase Inhibitor

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver Tier 5 - Specialty ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Xeljanz 		Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Xeljanz 		Tier 5 - Non-Preferred Specialty ✓ — — PA
BCBS Federal Basic Option 2026
via Xeljanz 		Tier 5 - Non-Preferred Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Advantage 2026
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Local 2026
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Care 2026
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ Restricted Access PA | QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3000 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 3600 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver 5000 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold RD CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze RD 5000 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold 1500 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Silver
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Gold CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Silver CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Connect Bronze CMS Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 30 per 30 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Xeljanz 		Tier 1 - Preferred Generic ✓ — ✓ 300 per 30 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Xeljanz 		Tier 1 - Preferred Generic ✓ — ✓ 300 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Xeljanz 		Tier 1 - Preferred Generic ✓ — ✓ 300 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Enhanced (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature Care (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Prime (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Value Plus (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Assist Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Giveback Open (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Simple (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Senior Care (HMO I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 300 per 30 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 300 per 30 days PA | QL
HealthTeam Advantage Plan II (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 300 per 30 days PA | QL
HealthTeam Advantage Plan I (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 300 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Enhanced (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Enhanced (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Aetna Medicare Signature (PPO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ 480 per 24 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Xeljanz 		Preferred ✓ ✓ — PA | ST
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Xeljanz 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - HDHP 2026
via Xeljanz 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via Xeljanz 		Tier 5 - Preferred Brand Specialty ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Secure | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Secure
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 13 hours, 44 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 5 - Specialty ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Xeljanz 		Tier 5 - Specialty ✓ — ✓ PA | QL
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