Xtampza

Generic: Abuse-Deterrent

9MG, 13.5MG, 18MG, 27MG, 36MG — Capsule

OPIOID AGONISTS

Also known as: Abuse-Deterrent XTAMPZA ER C12A 9MG, 13.5MG, 18MG, 27MG, 36MG Xtampza Er 9 Mg Capsule Xtampza Er 13.5 Mg Capsule Xtampza Er 18 Mg Capsule Xtampza Er 27 Mg Capsule Xtampza Er 36 Mg Capsule XTAMPZA ER C12A 9MG, 13.5MG, 18MG, 27MG XTAMPZA ER C12A 36MG XTAMPZA ER C12A 9MG, 13.5MG, 18MG,
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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: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Abuse-Deterrent 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 180 per 30 days QL
Aetna Medicare Enhanced (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Prime (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via Abuse-Deterrent 		Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CORE 001 NC (HMO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Abuse-Deterrent 		Tier 5 - Specialty ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Chronic Care CKM | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Simple Diabetes | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic 4700 | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Classic Standard | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic Standard | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic Standard
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Diabetes
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Gold Elite Saver Plus
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple PCP Saver
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Classic 4700
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Secure
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Classic
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Bronze Elite + PCP Saver Plus
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Secure | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
AIAN Cost Share
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Abuse-Deterrent 		Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 15 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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