Premarin

Generic: estrogens, conjugated

0.625 MG — Tablet

ESTROGENS

Also known as: PREMARIN TABS .3MG, .45MG, .625MG, .9MG, 1.25MG estrogens, conjugated (USP) Premarin 0.3 Mg Tablet Premarin 0.45 Mg Tablet Premarin 0.625 Mg Tablet Premarin 0.9 Mg Tablet Premarin 1.25 Mg Tablet PREMARIN TABS .3MG, .45MG, .625MG, .9MG, Premarin Oral Tablet Estrogens, Conjugated (USP)
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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: 21 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Elite Bronze with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Streamlined Silver
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Complete Gold
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Silver
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Gold
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via estrogens, conjugated (USP) 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Streamlined Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Streamlined Silver Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 3 - Preferred Brand — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health 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
Complete Gold 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
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Signature Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Signature Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Signature Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 21 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Premier + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — ✓ — ST
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via estrogens, conjugated 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via estrogens, conjugated 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via estrogens, conjugated 		Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 36 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — — None
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3600 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via estrogens, conjugated (USP) 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 2 - Generic — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 3 - Preferred Brand — — — None
Troy Medicare (HMO) Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Blue Medicare PPO Enhanced (PPO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via estrogens, conjugated (USP) 		Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-137 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-233 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H1036-307 (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H1036-335 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5216-017 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Full Access H5525-034 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice Giveback H5525-035 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-049 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-070 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H5525-072 (PPO D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-083 (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-025 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-026 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-057 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-060 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Plus H6622-061 (HMO-POS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via estrogens, conjugated (USP) 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via estrogens, conjugated 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via estrogens, conjugated 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via estrogens, conjugated 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Diabetes Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Secure | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 Tier 3 - Preferred Brand — — ✓ QL
Secure Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 21 hours, 35 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals) Tier 4 - Non-Preferred — — — None
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