Mounjaro

Generic: tirzepatide

2.5MG/0.5ML, 5MG/0.5ML, 7.5MG/0.5ML, 10MG/0.5ML, 12.5MG/0.5ML, 15MG/0.5ML — Pen Injector

ANTIDIABETICS

Also known as: tirzepatide Mounjaro 2.5 Mg/0.5 Ml Pen Mounjaro 5 Mg/0.5 Ml Pen Mounjaro 7.5 Mg/0.5 Ml Pen Mounjaro 10 Mg/0.5 Ml Pen Mounjaro 12.5 Mg/0.5 Ml Pen Mounjaro 15 Mg/0.5 Ml Pen MOUNJARO SOAJ 2.5MG/0.5ML, 5MG/0.5ML, 7.5MG/0.5ML, 10MG/0.5ML, 12.5MG/0.5ML, 15MG/0.5ML
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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: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze Tier 3 - Preferred Brand — — ✓ QL
Signature Silver Tier 3 - Preferred Brand — — ✓ QL
Signature Gold Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Signature Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Signature Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Streamlined Silver Tier 3 - Preferred Brand — — ✓ QL
Streamlined Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 3 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 14 hours, 58 minutes ago
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 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Focus 2026 Tier 2 - Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand ✓ — ✓ Restricted Access PA | QL
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Gold CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect myDiabetesCare Silver Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 3600 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Gold RD CMS Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 2 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Erickson Advantage Liberty (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Liberty Medicare Advantage (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthTeam Advantage Plan I (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Simple Open (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Giveback Open (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Prime (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 4 per 365 days PA | QL
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Senior Care (HMO I-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Troy Medicare (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — ✓ 2 per 28 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Zepbound
Zepbound is the same molecule (tirzepatide) but is indicated for weight management, while Mounjaro is for type 2 diabetes. Coverage may differ by indication. 		Tier 4 - Non-Preferred ✓ — ✓ 2.4 per 28 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Zepbound
Zepbound is the same molecule (tirzepatide) but is indicated for weight management, while Mounjaro is for type 2 diabetes. Coverage may differ by indication. 		Tier 4 - Non-Preferred ✓ — ✓ 2.4 per 28 days PA | QL
Troy Medicare (HMO)
via Zepbound
Zepbound is the same molecule (tirzepatide) but is indicated for weight management, while Mounjaro is for type 2 diabetes. Coverage may differ by indication. 		Tier 4 - Non-Preferred ✓ — ✓ 2.4 per 28 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 6 - Specialty Plus ✓ — ✓ 2 per 28 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Zepbound
Zepbound is the same molecule (tirzepatide) but is indicated for weight management, while Mounjaro is for type 2 diabetes. Coverage may differ by indication. 		Preferred ✓ — — PA
NC Medicaid Preferred Drug List 2026 Preferred ✓ ✓ — PA | ST
Source: CMS QHP JSON  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via tirzepatide 		Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 14 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 3 - Preferred Brand ✓ — ✓ PA | QL
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