Xpovio
Generic: selinexor
10MG, 40MG, 50MG, 60MG, 80MG — Tablet
Also known as:
XPOVIO 60 MG TWICE WEEKLY TBPK 20MG
XPOVIO 80 MG TWICE WEEKLY TBPK 20MG
Xpovio 80 Mg Twice Weekly
Xpovio 60 Mg Twice Weekly
XPOVIO TBPK 10MG, 40MG, 50MG, 60MG
selinexor
XPOVIO TBPK 10MG, 40MG, 50MG, 60MG, 80MG
Xpovio (60 MG Twice Weekly) Oral Tablet Therapy Pack
Selinexor
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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.
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
2 plansBlue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Advantage 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Local 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Care 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Value 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 5 - Specialty | ✓ | — | ✓ Limited Distribution | PA | QL |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Enhanced (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Blue Medicare Choice (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Blue Medicare Essential (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Wellcare Simple (HMO-POS) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Senior Care (HMO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Experience Health Medicare Advantage (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice H5216-211 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Enhanced (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Full Access H5525-034 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice H5525-049 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice H5525-050 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice H5525-070 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HumanaChoice H5525-083 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HealthSpring True Choice (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Prime (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature Care (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Wellcare Giveback Open (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Assist Open (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Wellcare Simple Open (PPO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Signature (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
| Aetna Medicare Value Plus (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16 per 28 days | PA | QL |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 6 - Non-Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - HDHP 2026 | Tier 6 - Non-Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 6 - Non-Preferred Brand Specialty | ✓ | — | ✓ | PA | QL |