Xtampza

Generic: Abuse-Deterrent

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

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.

Ambetter (Centene)

29 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Everyday Bronze via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite 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
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold 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 via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver with Atrium Health via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold with Atrium Health 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
Standard Expanded Bronze + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Silver with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Standard Gold with Atrium Health + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + 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
Everyday Bronze + Vision + Adult Dental via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental 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

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Gold Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Signature + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Bronze Essential + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Premier + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA
AmeriHealth Caritas Next Silver Essential + No Referrals via Abuse-Deterrent	Tier 2 - Generic	✓	—	—	PA

Blue Cross Blue Shield Federal

2 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 52 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

Medicare Part D

76 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage 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 Diabetes & Heart Care (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) 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
UHC Dual Complete NC-S3 (HMO-POS 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
UHC Dual Complete NC-S001 (PPO D-SNP)	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
AARP Medicare Advantage Access from UHC NC-23 (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 from UHC NC-0004 (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-0017 (PPO)	Tier 4 - Non-Preferred	—	—	✓ 180 per 30 days	QL
AARP Medicare Advantage from UHC NC-0019 (PPO)	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
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	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
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	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
AARP Medicare Advantage from UHC NC-0009 (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-0012 (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 Giveback from UHC NC-14 (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 from UHC NC-0015 (HMO-POS)	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
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 180 per 30 days	QL
Erickson Advantage Signature (HMO-POS)	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 Freedom (HMO-POS)	Tier 4 - Non-Preferred	—	—	✓ 180 per 30 days	QL
Erickson Advantage Liberty (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
UHC Complete Care NC-27 (HMO-POS C-SNP)	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
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	✓ 180 per 30 days	QL
Aetna Medicare Signature (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 Value Plus (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 Signature Care (HMO) 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 Enhanced (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
Aetna Medicare Signature (PPO) via Abuse-Deterrent	Tier 4 - Non-Preferred	✓	—	✓ 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 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 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 GIVEBACK 012 NC (HMO) 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 008 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
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

NC State Health Plan

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026	Not Covered	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Simple PCP Saver \| 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 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
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
Silver Simple PCP Saver 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
AIAN Cost Share via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
AIAN Cost Share \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Classic Standard via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze 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
Gold Classic Standard \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Elite + PCP Saver Plus via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Classic via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Secure via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic 4700 via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Chronic Care CKM \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Gold Elite Saver Plus via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Secure \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Bronze Classic 4700 \| 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
Silver Classic \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL
Silver Simple Diabetes \| with Atrium Health via Abuse-Deterrent	Tier 2 - Generic	—	—	✓	QL

UnitedHealthcare

13 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 12 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Standard (No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Standard (No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, 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 Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Standard (No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, 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