Tresiba

Generic: insulin degludec

100UNIT — Pen Injector

ANTIDIABETICS

Also known as: TRESIBA SOLN 100UNIT/ML insulin degludec Tresiba 100 Unit/Ml Vial
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Silver + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Silver with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — — None
Everyday Bronze Tier 3 - Preferred Brand — — — None
Elite Bronze Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze Tier 3 - Preferred Brand — — — None
Standard Silver Tier 3 - Preferred Brand — — — None
Standard Gold Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Elite Bronze
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Silver
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Gold
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Standard Expanded Bronze with Atrium Health
via Xultophy 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Xultophy 		Tier 3 - Non-Preferred Brand ✓ — — PA
BCBS Federal Standard Option 2026
via Xultophy 		Tier 3 - Non-Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Tresiba Flextouch 		Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via Tresiba Flextouch 		Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Local 2026
via Tresiba Flextouch 		Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Care 2026
via Tresiba Flextouch 		Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Value 2026
via Tresiba Flextouch 		Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — ✓ QL
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — ✓ QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 2 - Preferred Brand — — ✓ QL
Cigna Plus NC 4-Tier Formulary 2026
via Tresiba Flextouch 		Tier 2 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Dual (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Value Plus (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Prime (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature Care (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Enhanced (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Enhanced (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Enhanced (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature Extra (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature Giveback (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Signature (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring True Choice (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring Preferred (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring Preferred Select (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring Preferred Savings (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthSpring Preferred Plus (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Xultophy 		Tier 3 - Preferred Brand — — ✓ 15 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 6 - Specialty Plus — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Tresiba Flextouch 		Non-Preferred — ✓ — ST
NC Medicaid Preferred Drug List 2026
via Xultophy 		Non-Preferred ✓ ✓ — PA | ST
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Xultophy 		Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - HDHP 2026 Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - 70/30 Standard PPO 2026 Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - 80/20 Plus PPO 2026 Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - HDHP 2026
via Xultophy 		Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - 70/30 Standard PPO 2026
via Xultophy 		Tier 0 - $0 Copay (ACA Preventive) — — ✓ $0 Copay per 30-day QL
NC State Health Plan - 70/30 Standard PPO 2026
via Insulin Degludec 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via Insulin Degludec 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Insulin Degludec 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jan 5, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via Insulin Degludec 		Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 20 hours, 37 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Insulin Degludec 		Unknown — — ✓ QL
UnitedHealthcare NC Individual & Family 2026
via Tresiba Flextouch 		Unknown — — ✓ QL
UnitedHealthcare NC Individual & Family 2026 Unknown — — ✓ QL
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