Zenatane

Generic: isotretinoin

10mg, 20mg, 30mg, 40mg — Capsule

Also known as: zenatane caps 10mg, 20mg, 40mg zenatane caps 30mg isotretinoin Zenatane 10 Mg Capsule Zenatane 20 Mg Capsule Zenatane 30 Mg Capsule Zenatane 40 Mg Capsule zenatane caps 10mg, 20mg, 30mg, 40mg Zenatane Caps 10mg, 20mg, 40mg Zenatane Caps 30mg

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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)

145 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Standard Gold via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health + Vision + Adult Dental via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold with Atrium Health via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Everyday Bronze with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Elite Bronze with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Gold + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health + Vision + Adult Dental via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Clear Silver with $0 Insulin Options via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Silver with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Standard Expanded Bronze with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Complete Gold with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Focused Silver with Atrium Health via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 21 hours, 40 minutes ago

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

Blue Cross Blue Shield Federal

17 plans

Source: PDF · Formulary date: Aug 7, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Amnesteem	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via isotretinoin	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via isotretinoin	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via isotretinoin	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Amnesteem	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Claravis	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via Claravis	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Claravis	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via Amnesteem	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Accutane	Tier 1 - Generic	—	—	—	None
BCBS Federal Basic Option 2026 via Accutane	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via Accutane	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via Absorica	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026 via Absorica	Tier 3 - Non-Preferred Brand	✓	—	—	PA

Blue Cross Blue Shield of NC

5 plans

Source: PDF · Formulary date: Aug 1, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Care 2026 via Absorica	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Absorica	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Absorica	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Absorica	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Absorica	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

100 plans

Source: PDF · Formulary date: Aug 21, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 3500 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3500 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Bronze via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect myDiabetesCare Silver via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold 1500 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze RD CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Gold RD CMS Standard via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze CMS Standard via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 3000 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 6500 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Connect Silver 4400 Indiv Med Deductible via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None

Medicare Part D

687 plans

Source: CMS QHP JSON · Formulary date: Aug 19, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Accutane	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Accutane	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Amnesteem	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Accutane	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Accutane	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Accutane	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Essential Plan (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via isotretinoin	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health 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
Provider Partners North Carolina Advantage Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP)	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Provider Partners North Carolina Community Plan (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP) via Claravis	Tier 1 - Preferred Generic	—	—	—	None
Troy Medicare (HMO) via Claravis	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Claravis	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Accutane	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Claravis	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via isotretinoin	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via isotretinoin	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Claravis	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Accutane	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Claravis	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Amnesteem	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via Amnesteem	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Amnesteem	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Accutane	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Amnesteem	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Amnesteem	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Amnesteem	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Amnesteem	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via isotretinoin	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via isotretinoin	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via isotretinoin	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Accutane	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Accutane	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP)	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Amnesteem	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Claravis	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Claravis	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Claravis	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Plan I (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Amnesteem	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS)	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple Open (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Giveback Open (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Simple (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via isotretinoin	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Accutane	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H1036-137 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S2 (PPO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Liberty Open (PPO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0001 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0004 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0016 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0017 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0019 (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Dual (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Value Plus (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Prime (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Care (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Full Dual Care (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Chronic Care Value (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare PPO Enhanced (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential Plus (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Enhanced (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Choice (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Blue Medicare Essential (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Experience Health Medicare Advantage (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Wellcare Dual Access (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-25 (HMO-POS C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-27 (HMO-POS C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
UHC Complete Care NC-28 (HMO-POS C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Alignment Health Platinum (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 002 NC (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL 009 NC (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED GIVEBACK 012 NC (HMO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Enhanced (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Extra (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature Giveback (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Aetna Medicare Signature (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Full Access H5525-034 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Guardian (HMO-POS I-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Champion (HMO-POS C-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Freedom (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Erickson Advantage Liberty (HMO-POS) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
Humana Gold Plus H6622-025 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 001 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 003 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 005 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE 008 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Claravis	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring TotalCare Plus (HMO D-SNP) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Select (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Savings (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring Preferred Plus (HMO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO) via Claravis	Tier 4 - Non-Preferred	—	—	—	None

NC State Health Plan

18 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Claravis	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026 via Claravis	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - HDHP 2026 via isotretinoin	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026 via isotretinoin	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via isotretinoin	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - HDHP 2026 via Claravis	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026 via Accutane	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026 via Amnesteem	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via Amnesteem	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - HDHP 2026 via Amnesteem	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - HDHP 2026	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via Accutane	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - HDHP 2026 via Accutane	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 70/30 Standard PPO 2026	Tier 2 - Non-Preferred Generic	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026 via Absorica	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Absorica	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Absorica	Not Covered	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Bronze Classic Standard via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via isotretinoin	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via isotretinoin	Tier 2 - Generic	—	—	—	None
Secure via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Classic via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via isotretinoin	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via isotretinoin	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via isotretinoin	Tier 2 - Generic	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via isotretinoin	Tier 3 - Non-Formulary	✓	—	—	PA

UnitedHealthcare

85 plans

Source: PDF · Formulary date: Aug 25, 2026 · Checked: 21 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
54332NC0060010 via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060010	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060009	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060008	Tier 4 - Non-Preferred	—	—	—	None
54332NC0030042	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals)	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Claravis	Tier 4 - Non-Preferred	—	—	—	None
54332NC0030042 via Claravis	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060008 via Claravis	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060009 via Claravis	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060010 via Accutane	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060009 via Accutane	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060008 via Accutane	Tier 4 - Non-Preferred	—	—	—	None
54332NC0030042 via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard (No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
54332NC0030042 via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060008 via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060009 via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060010 via Amnesteem	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Standard (No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Gold Standard (No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals) via Accutane	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060010 via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060009 via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
54332NC0060008 via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None
54332NC0030042 via isotretinoin	Tier 4 - Non-Preferred	—	—	—	None