Denavir

Generic: penciclovir

Cream

Antiviral

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Silver
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Clear Silver with $0 Insulin Options
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 17 hours, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via penciclovir 		Tier 1 - Preferred Generic — — ✓ 5 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via penciclovir 		Tier 2 - Generic — — ✓ 5 per 30 days QL
Troy Medicare (HMO)
via penciclovir 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via penciclovir 		Tier 2 - Generic — — — None
HealthSpring Preferred Savings (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring Preferred (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring True Choice (PPO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health AVA (PPO)
via penciclovir 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring Preferred Select (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
Alignment Health Platinum (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Alignment Health smartHMO (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Alignment Health Platinum Select (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 hours, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
NC Medicaid Preferred Drug List 2026
via penciclovir 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via penciclovir 		Unknown — — ✓ QL
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