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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: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 3 hours, 47 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible 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
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 3 hours, 47 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — ✓ — ST
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — ✓ ✓ 30 per 30 days ST | QL
Troy Medicare (HMO) Tier 2 - Generic — ✓ — ST
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
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 Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
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