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)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze | 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 |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Complete Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold | Tier 2 - Generic | — | — | ✓ | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | ✓ | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
7 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Zonisade |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Zonegran |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Zonegran |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Zonisade |
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 Value 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
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Local 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Care 2026
via Zonegran |
Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Care 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 Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | 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 CMS Standard | Tier 2 - Generic | — | — | — | None |
Medicare Part D
280 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
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) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-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)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | — | ✓ | — | ST |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
|
Longevity Health Plan (HMO I-SNP)
via Zonisade |
Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Senior Care (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)
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 |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | 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 |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | 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 |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | 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 |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (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 |
| 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 |
| 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 |
| Healthy Blue + Medicare (HMO-POS D-SNP) | 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 |
| 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 |
| Alignment Health AVA (PPO) | 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 |
| 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 |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (HMO 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 |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | 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 |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Champion (HMO-POS 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 Enhanced (HMO) | 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 |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| HealthSpring Preferred (HMO) | 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 |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
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 |
|
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 |
|
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 |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Signature (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Freedom (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Liberty (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 |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
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 |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health Platinum (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health smartHMO (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 Platinum Select (HMO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
Alignment Health AVA (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | — | — | None |
|
HealthTeam Advantage Plan I (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Plan II (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Vitality Plan (PPO)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | — | ST |
|
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 |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | — | ✓ | ✓ 900 per 30 days | ST | QL |
|
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 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 |
|
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 |
|
Humana Full Access H5525-034 (PPO)
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 |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
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 H5525-050 (PPO)
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 |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HumanaChoice H5525-083 (PPO)
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 |
|
Humana Gold Plus H6622-026 (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 H6622-057 (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 H6622-061 (HMO-POS)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
Humana Gold Choice H8145-004 (PFFS)
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 |
|
Senior Care (HMO I-SNP)
via Zonisade |
Tier 4 - Non-Preferred | ✓ | — | ✓ 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 |
|
Wellcare Simple Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Simple (HMO-POS)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Giveback Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Assist Open (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
Wellcare Dual Access (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 DUAL 009 NC (HMO D-SNP)
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 C-SNP PREMIUM 018 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 |
|
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 |
|
Aetna Medicare Chronic Care (HMO C-SNP)
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 |
|
Aetna Medicare Signature (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 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 (PPO)
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 Full Dual Care (HMO D-SNP)
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 Prime (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 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 Chronic Care Value (HMO C-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
HealthSpring True Choice (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring TotalCare (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via Zonisade |
Tier 5 - Specialty | ✓ | — | — | PA |
|
HealthSpring Preferred (HMO)
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 |
|
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 CHOICE 008 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE GIVEBACK 006 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 GIVEBACK 004 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 002 NC (PPO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
|
DEVOTED CHOICE 001 NC (PPO)
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 GIVEBACK 002 NC (HMO)
via Zonisade |
Tier 5 - Specialty | ✓ | — | ✓ 900 per 30 days | PA | QL |
NC Medicaid PDL
2 plansNC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| 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
via Zonegran |
Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Zonegran |
Not Covered | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Zonegran |
Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Gold Elite Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| 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 PCP Saver | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 1 - Preferred Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 1 - Preferred Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - 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 |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, 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 Bronze Standard (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 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |