zonisamide
Generic: Zonisade
25mg, 50mg, 100mg — Capsule
Also known as:
zonisamide oral
Zonegran
zonisamide caps 25mg, 50mg, 100mg
zonisamide cap 25 mg, 100 mg
zonisamide cap 50 mg
Zonisamide 100 Mg Capsule
Zonisamide 25 Mg Capsule
Zonisamide 50 Mg Capsule
Zonisamide Oral Capsule
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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)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 2 - Generic | — | — | ✓ | QL |
| Streamlined Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Streamlined Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Expanded Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Signature Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
AmeriHealth Caritas NC
11 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
7 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 Basic Option 2026
via Zonegran |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Zonisade |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Zonisade |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Zonegran |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Care 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Value 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Care 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Local 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Value 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3600 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
Medicare Part D
280 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
|
NHC Advantage (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | ✓ 900 per 30 days | PA | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home 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 Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Dual Plan (HMO D-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
PruittHealth Premier (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Longevity Health Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring Preferred (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
|
Troy Medicare (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HumanaChoice Giveback H5216-017 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice H5216-211 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Signature (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HumanaChoice H5525-083 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice H5525-070 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice H5525-050 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice H5525-049 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice Giveback H5525-035 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Full Access H5525-034 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health Platinum Select (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health smartHMO (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Humana Gold Plus H1036-137 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H1036-233 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H1036-335 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Vitality Plan (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Plan II (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Plan I (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | ✓ 900 per 30 days | ST | QL |
|
Humana Gold Choice H8145-004 (PFFS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Alignment Health AVA (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Humana Gold Plus H6622-061 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H6622-057 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H6622-026 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Plus H6622-025 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Liberty Medicare Advantage (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Blue Medicare PPO Enhanced (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Blue Medicare Essential Plus (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Blue Medicare Enhanced (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Blue Medicare Choice (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Blue Medicare Essential (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Experience Health Medicare Advantage (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Erickson Advantage Liberty (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Freedom (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Alignment Health Platinum (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Senior Care (HMO I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Wellcare Simple Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Assist Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Giveback Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Aetna Medicare Signature (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Dual (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Value Plus (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Prime (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature Care (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Wellcare Simple (HMO-POS)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Access (HMO-POS D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
DEVOTED CORE 001 NC (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Enhanced (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature Extra (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature Giveback (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Aetna Medicare Signature (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HealthSpring True Choice (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
DEVOTED CHOICE 001 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Select (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Savings (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred Plus (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
NC Medicaid PDL
2 plansNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Zonegran |
Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Zonegran |
Not Covered | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via Zonegran |
Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AIAN Cost Share | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
UnitedHealthcare
17 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |