Zenpep

Generic: amylase

126000 UNIT — Delayed Release Capsule

DIGESTIVE AIDS

Also known as: ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT ZENPEP CAP 60000UNT amylase Zenpep Dr 3,000 Unit Capsule Zenpep Dr 40,000 Unit Capsule Zenpep Dr 5,000 Unit Capsule Zenpep Dr 10,000 Unit Capsule Zenpep Dr 15,000 Unit Capsule Zenpep Dr 20,000 Unit Capsule Zenpep Dr 25,000 Unit Capsule Zenpep Dr 60,000 Unit Capsule Zenpep Oral Capsule Delayed Release Particles
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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, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental 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 Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental 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 Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental 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 Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — — None
Everyday Bronze Tier 3 - Preferred Brand — — — None
Elite Bronze Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options 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 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 Tier 3 - Preferred Brand — — — None
Standard Gold Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental 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 Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze
via Creon 		Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Silver + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Gold + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Everyday Bronze
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Elite Bronze
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Silver
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Gold
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Complete Gold
via Pancreaze 		Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Checked: 14 hours, 34 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 Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Creon 		Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Brand-Preferred — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals 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: 14 hours, 34 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 Tier 2 - Preferred Brand — — — None
BCBS Federal Focus 2026
via Creon 		Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026
via Pancreaze 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Pancreaze 		Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 34 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 Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand ✓ — — PA
BCBSNC Blue Advantage 2026 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: 14 hours, 34 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
Provider Partners North Carolina Community Plan (HMO I-SNP) 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) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Creon 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) 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) 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) 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) Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS) Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Creon 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO) 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) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand — — — None
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand — — — None
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand — — — None
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) 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) Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO) 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) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Plan II (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 3 - Preferred Brand — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) 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) Tier 3 - Preferred Brand — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) 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) 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) Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) 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) Tier 3 - Preferred Brand — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 3 - Preferred Brand — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 3 - Preferred Brand — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Signature (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Freedom (HMO-POS) Tier 3 - Preferred Brand — — — None
Erickson Advantage Liberty (HMO-POS) 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) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 3 - Preferred Brand — — — None
Erickson Advantage Champion (HMO-POS C-SNP) 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) 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) 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 Signature (PPO) 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 Enhanced (HMO) Tier 4 - Non-Preferred — — — None
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
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) 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
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — — None
HumanaChoice H5216-211 (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
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
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 Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 34 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 Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 14 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 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 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
via Pancreaze 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Pancreaze 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Pancreaze 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Checked: 14 hours, 34 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 Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share | with Atrium Health
via Creon 		Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share Tier 3 - Preferred Brand ✓ — — PA
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Classic | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Secure | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Simple Diabetes Tier 3 - Preferred Brand ✓ — — PA
Gold Elite Saver Plus Tier 3 - Preferred Brand ✓ — — PA
Silver Simple PCP Saver Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic 4700 Tier 3 - Preferred Brand ✓ — — PA
Secure Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Tier 3 - Preferred Brand ✓ — — PA
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand ✓ — — PA
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — — PA
Bronze Classic Standard | with Atrium Health 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 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: 14 hours, 34 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) Tier 3 - Preferred Brand — — — None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Standard (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Bronze Standard+ Dental + Vision (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) 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) 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 Tier 3 - Preferred Brand — — — None
UHC Gold Standard (No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) Tier 3 - Preferred Brand — — — None
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