Pancreaze

Generic: amylase

600 Unit — Delayed Release Capsule

DIGESTIVE ENZYMES

Also known as: PANCREAZE CAP 2600UNIT PANCREAZE CAP 4200UNIT PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT PANCREAZE CAP 37000 amylase Pancreaze Dr 2,600 Unit Capsule Pancreaze Dr 4,200 Unit Capsule Pancreaze Dr 10,500 Unit Capsule Pancreaze Dr 16,800 Unit Capsule Pancreaze Dr 21,000 Unit Capsule Pancreaze Dr 37,000 Unit 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.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Focused Silver with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Creon 		Tier 3 - Preferred Brand — — — None
Complete Gold
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options
via Creon 		Tier 3 - Preferred Brand — — — None
Elite Bronze
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Silver
via Creon 		Tier 3 - Preferred Brand — — — None
Complete Gold
via Zenpep 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Zenpep 		Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Zenpep 		Tier 3 - Preferred Brand — — — None
Elite Bronze
via Zenpep 		Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options
via Zenpep 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze
via Zenpep 		Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Silver
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Gold
via Zenpep 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Gold
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental
via Creon 		Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Zenpep 		Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Creon 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze Tier 4 - Non-Preferred — — — None
Elite Bronze Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze Tier 4 - Non-Preferred — — — None
Standard Silver Tier 4 - Non-Preferred — — — None
Standard Gold Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Zenpep 		Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Creon 		Brand-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Creon 		Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Creon 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Zenpep 		Tier 2 - Preferred Brand — — — None
BCBS Federal Focus 2026
via Creon 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026
via Creon 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Value 2026
via Zenpep 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Care 2026
via Zenpep 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Local 2026
via Zenpep 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Home with UNC Health Alliance 2026
via Zenpep 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Advantage 2026
via Zenpep 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Value 2026
via Creon 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Care 2026
via Creon 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Local 2026
via Creon 		Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Home with UNC Health Alliance 2026
via Creon 		Tier 3 - High Cost Brand ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Zenpep 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
DEVOTED CORE 001 NC (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan I (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-083 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-070 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-050 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5525-049 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Full Access H5525-034 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice H5216-211 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Dual (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Value Plus (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Prime (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Care (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Enhanced (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Extra (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature Giveback (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Zenpep 		Tier 3 - Preferred Brand — — — None
Senior Care (HMO I-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Choice H8145-004 (PFFS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Creon 		Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Zenpep 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Creon 		Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Zenpep 		Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026
via Zenpep 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Zenpep 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Creon 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Zenpep 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Creon 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Creon 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Gold Classic Standard | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Chronic Care CKM | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Diabetes | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Chronic Care CKM | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Secure | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Secure
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard | with Atrium Health
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard
via Zenpep 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Secure
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Secure | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Classic | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Chronic Care CKM | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Diabetes | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Chronic Care CKM | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 7 hours, 54 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Gold Standard (No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Standard (No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Silver Standard (No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Bronze Standard (No Referrals)
via Creon 		Tier 3 - Preferred Brand — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Gold Standard (No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Zenpep 		Tier 3 - Preferred Brand — — — None
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