Victoza 3-PAK

Generic: liraglutide

0.6 MG/0.1 — Pen Injector

METABOLIC DYSFUNCTION AGENTS

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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: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options
via liraglutide 		Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Streamlined Silver
via liraglutide 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Complete Gold
via liraglutide 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via liraglutide 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via liraglutide 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via liraglutide 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Silver
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Gold
via liraglutide 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health
via liraglutide 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via liraglutide 		Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Victoza 		Tier 3 - Preferred Brand — ✓ ✓ ST | QL
Source: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 5000 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 3600 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 3000 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Gold CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect myDiabetesCare Silver
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD 5000 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Gold RD CMS Standard
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP)
via liraglutide 		Tier 1 - Preferred Generic ✓ — ✓ 9 per 30 days PA | QL
NHC Advantage (HMO I-SNP)
via liraglutide 		Tier 1 - Preferred Generic ✓ — ✓ 9 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via liraglutide 		Tier 1 - Preferred Generic ✓ — ✓ 9 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP)
via liraglutide 		Tier 1 - Preferred Generic ✓ — ✓ 9 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via liraglutide 		Tier 1 - Preferred Generic ✓ — ✓ 9 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via liraglutide 		Tier 2 - Generic ✓ — ✓ 9 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via liraglutide 		Tier 2 - Generic ✓ — ✓ 9 per 30 days PA | QL
Troy Medicare (HMO)
via liraglutide 		Tier 2 - Generic ✓ — ✓ 9 per 30 days PA | QL
Senior Care (HMO I-SNP)
via liraglutide 		Tier 2 - Generic ✓ — ✓ 9 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via liraglutide 		Tier 2 - Generic ✓ — ✓ 9 per 30 days PA | QL
Wellcare Giveback Open (PPO)
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ 9 per 30 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via liraglutide 		Tier 3 - Preferred Brand ✓ — ✓ 9 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Victoza 		Preferred ✓ ✓ — PA | ST
NC Medicaid Preferred Drug List 2026
via Saxenda 		Non-Preferred ✓ — — PA
NC Medicaid Preferred Drug List 2026
via liraglutide 		Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 5 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
69803NC0010082
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Classic
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Secure
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Classic 4700
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple PCP Saver
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Diabetes
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Classic Standard
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Classic Standard
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Gold Classic Standard
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Secure | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010074
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010075
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010076
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010077
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010078
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010079
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010080
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010081
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010083
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010084
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010085
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Simple Diabetes
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Core Plan
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Core Plan | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010108
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010109
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010110
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010111
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010112
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010113
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010114
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010115
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010116
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
69803NC0010117
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via liraglutide 		Tier 2 - Generic ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 5 hours, 28 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via liraglutide 		Tier 3 - Non-Formulary ✓ — — PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026
via Saxenda 		Tier 3 - Non-Formulary ✓ — — PA PA: TPA - LEGEND ANTI-OBESITY DRUGS REQUIRES PRIOR AUTHORIZATION
TRICARE Uniform Formulary 2026
via Victoza 2-PAK 		Tier 3 - Non-Formulary ✓ — — PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary ✓ — — PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
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