Viread

Generic: tenofovir disoproxil fumarate

0.04 MG — Tablet

ANTIVIRALS

Also known as: tenofovir disoproxil fumarate Viread 150 Mg Tablet Viread 200 Mg Tablet Viread 250 Mg Tablet Viread Powder Viread Oral Tablet Viread Oral Powder Tenofovir disoproxil fumarate
GoodRx Compare Prices

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: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced CHF Heart Care Silver $0 Rx Options
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Complete Gold
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Signature Gold
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Signature Silver
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Streamlined Silver
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Streamlined Silver Tier 4 - Non-Preferred — — ✓ QL
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred — — ✓ QL
Complete Gold Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Signature Gold Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred — — ✓ QL
Signature Silver Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — ✓ QL
Signature Expanded Bronze Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Brand-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Brand-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via tenofovir disoproxil fumarate 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via tenofovir disoproxil fumarate 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via tenofovir disoproxil fumarate 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026
via Viread Powder 		Tier 2 - Preferred Brand — — — None
BCBS Federal Focus 2026
via Viread Powder 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Viread Powder 		Tier 2 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver 5000 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver 3600 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Viread Powder 		Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3600 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver Tier 3 - Preferred Brand — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
PruittHealth Premier (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
Longevity Health Plan (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
NHC Advantage (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
NHC Advantage (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Viread Powder 		Tier 1 - Preferred Generic — — ✓ 240 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Assist Open (PPO)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO)
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ 30 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-083 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare PPO Enhanced (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-070 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-050 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5525-049 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice H5216-211 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Humana Full Access H5525-034 (PPO)
via tenofovir disoproxil fumarate 		Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan II (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Plus (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Savings (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Select (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via tenofovir disoproxil fumarate 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Wellcare Simple Open (PPO) Tier 5 - Specialty — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 5 - Specialty — — — None
Wellcare Assist Open (PPO) Tier 5 - Specialty — — — None
Wellcare Giveback Open (PPO) Tier 5 - Specialty — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Signature (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Value Plus (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Prime (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Signature Care (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (HMO) Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 5 - Specialty — — — None
Blue Medicare PPO Enhanced (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Blue Medicare Choice (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Blue Medicare Essential (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Wellcare Simple (HMO-POS) Tier 5 - Specialty — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Senior Care (HMO I-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Troy Medicare (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 5 - Specialty — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 5 - Specialty — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 5 - Specialty — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 5 - Specialty — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature Extra (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature Giveback (PPO) Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO) Tier 5 - Specialty — — — None
Humana Full Access H5525-034 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring True Choice (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 5 - Specialty — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 5 - Specialty — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring Preferred (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 5 - Specialty — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health Platinum (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health smartHMO (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health Platinum Select (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature Extra (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature Giveback (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Humana Full Access H5525-034 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice H5525-049 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice H5525-050 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice H5525-070 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice H5525-083 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Erickson Advantage Signature (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Erickson Advantage Freedom (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Erickson Advantage Liberty (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Alignment Health AVA (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring True Choice (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Choice H8145-004 (PFFS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE 003 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE 005 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE 008 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
HealthSpring TotalCare (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring Preferred (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring Preferred Select (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring Preferred Savings (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthSpring Preferred Plus (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthTeam Advantage Plan I (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthTeam Advantage Plan II (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Wellcare Simple Open (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Assist Open (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Giveback Open (PPO)
via Viread Powder 		Tier 5 - Specialty — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Aetna Medicare Signature (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Dual (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Value Plus (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Prime (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Signature Care (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Enhanced (HMO)
via Viread Powder 		Tier 5 - Specialty — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Blue Medicare PPO Enhanced (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Blue Medicare Essential Plus (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Blue Medicare Enhanced (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Blue Medicare Choice (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Blue Medicare Essential (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Experience Health Medicare Advantage (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Wellcare Simple (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Viread Powder 		Tier 5 - Specialty — — — None
Senior Care (HMO I-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Troy Medicare (HMO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
HumanaChoice H5216-211 (PPO)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Viread Powder 		Tier 5 - Specialty — — ✓ 240 per 30 days QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via tenofovir disoproxil fumarate 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Viread Powder 		Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
NC State Health Plan - 80/20 Plus PPO 2026
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
NC State Health Plan - 70/30 Standard PPO 2026
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
NC State Health Plan - 70/30 Standard PPO 2026
via Viread Powder 		Tier 3 - Non-Preferred Brand — — ✓ QL
NC State Health Plan - 80/20 Plus PPO 2026
via Viread Powder 		Tier 3 - Non-Preferred Brand — — ✓ QL
NC State Health Plan - HDHP 2026
via Viread Powder 		Tier 3 - Non-Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic Standard | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Gold Classic Standard | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Secure | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Classic | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Simple Diabetes | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Secure
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Classic
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Classic 4700
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Silver Classic Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Gold Classic Standard
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health
via tenofovir disoproxil fumarate 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Secure | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Secure Tier 3 - Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 18 hours, 48 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via tenofovir disoproxil fumarate 		Tier 1 - Preferred Generic — — — None
Something not right?