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, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options
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
Complete Gold
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
Everyday Bronze
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Everyday Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Elite Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Focused Silver with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Complete Gold with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Expanded Bronze with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Silver with Atrium Health
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
Standard Gold with Atrium Health
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
Complete Gold + Vision + Adult Dental
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
Source: CMS QHP JSON  ·  Checked: 17 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + No Referrals
via penciclovir 		Tier 2 - Generic ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect myDiabetesCare Silver
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Gold 1500 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver 3500 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze RD 5000 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver 4400 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver 3000 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Gold CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Bronze CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Gold RD CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver RD CMS Standard
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible
via penciclovir 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 23 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
Troy Medicare (HMO)
via penciclovir 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via penciclovir 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via penciclovir 		Tier 2 - Generic — — ✓ 5 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via penciclovir 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
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 TotalCare Plus (HMO D-SNP)
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 Preferred Select (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring Preferred Savings (HMO)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ 5 per 30 days QL
HealthSpring Preferred Plus (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 AVA (PPO)
via penciclovir 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 23 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: Jun 23, 2026  ·  Checked: 17 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Standard (No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard+ Dental + Vision (No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard (No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Standard (No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via penciclovir 		Tier 4 - Non-Preferred — — ✓ QL
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