FirstCarolinaCare Preferred Drug List (PDL)
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1 FirstCarolinaCare Preferred Drug List (PDL) 2-tier Drug Plan Member What is the MedImpact Preferred Drug List (PDL)? The PDL is a list of commonly prescribed medications within select classes of drugs covered by your prescription drug plan. The PDL was created to promote clinically appropriate utilization of medications in a cost-effective manner. Nonpreferred drugs listed below are considered Non-Formulary (not routinely covered) under a 2-tier prescription plan. A Non-Formulary exception must be requested by your physician for consideration of coverage of a Non-Formulary / Non-Preferred Drug. Who decides what medications make up the PDL? The list is developed and maintained by a committee comprised of physicians and pharmacists (the Pharmacy and Therapeutics Committee). Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. Are the medications listed on the PDL the only drugs my physician can prescribe for me? No. The PDL is a select list of commonly prescribed drugs and does not represent all preferred formulary medications available under your plan. The PDL does not limit your prescription coverage, but is provided to encourage the use of preferred generic and brand name drugs within major therapeutic drug classes (e.g., Cardiovascular, Diabetes, etc.). For complete formulary information, visit your MedImpact Member Website link in the Rx Corner at or call Pharmacy Customer Service at (800) How do I get the greatest benefit from my PDL? Print out the Preferred Drug List and take it with you when visiting your physician. Ask your physician to prescribe generic medications whenever possible. All FDA approved generic drugs are considered preferred medications and should reduce your copays. When there is more than one brand name drug available for your medical condition, ask your physician to prescribe a preferred drug listed on your PDL. This should also reduce your copays. Please note: The MedImpact PDL is subject to change due to updates and availability of generic alternatives. Please refer to the MedImpact web site at for the most up-to-date PDL. The PDL is not a complete list of formulary drugs; therefore, you should refer to your plan for a complete drug list and details of any additional coverage or quantity limit restrictions that may apply to certain medications. ALLERGY NASAL CORTICOSTEROIDS OPHTHALMIC ANTIHISTAMINES BEHAVIORAL HEALTH ADHD AGENTS ANTIPSYCHOTICS OTC budesonide flunisolide (QL) fluticasone (QL) mometasone (QL) OTC triamcinolone azelastine (QL) olopatadine (QL) dextroamphetamine/ amphetamine (QL) methylphenidate (QL) aripiprazole (QL) aripiprazole ODT/PO Solution (QL, ST) clozapine (QL, ST) olanzapine (QL) quetiapine IR/XR (QL) Qnasl (QL, ST) Adderall XR (QL) Concerta (QL,AGE) Quillichew (QL,ST) Quillivant (QL,ST) Vyvanse (QL,ST) Latuda (QL, ST) Rexulti (QL, ST) Saphris (QL, ST) Vraylar (QL, ST) Beconase AQ (QL, ST) Dymista (QL, ST) Omnaris (QL, ST) Ticanase (QL) Xhance (QL, ST) Zetonna (QL, ST) Bepreve (QL, ST) Emadine (QL, ST) Lastacaft (QL, ST) Pazeo (QL, ST) Adzenys ER (QL, ST) Adzenys XR-ODT (QL, ST) Aptensio XR (QL, ST,AGE) Cotempla XR-ODT (QL, ST) Daytrana (QL, ST) Dyanavel XR (QL, ST) Mydayis (QL, ST) Zenzedi (QL, ST) Fanapt (QL, ST) Fazaclo (QL, ST) Invega (QL, ST) Versacloz (QL, ST) Page 1
2 risperidone (QL) ziprasidone (QL) CARDIOVASCULAR LIPID-LOWERING AGENTS ANTICOAGULANTS atorvastatin (QL) ezetimibe (QL) fluvastatin IR/ER (QL, ST) lovastatin (QL) pravastatin (QL) rosuvastatin(ql) simvastatin(ql) (ST on 80mg) simvastatin/ezetimibe (QL, ST on 80mg) Livalo (QL) Xarelto (QL) Eliquis (QL) DERMATOLOGY TOPICAL ACNE AGENTS clindamycin/tretinoin Ziana DIABETES DPP-4 INHIBITORS SGLT-2 INHIBITORS Januvia (QL) Janumet (QL) Janumet XR (QL) Jentadueto (QL) Jentadueto XR (QL) Tradjenta (QL) Farxiga (QL, ST) Jardiance (QL,ST) Synjardy (QL,ST) Synjardy XR (QL,ST) Xigduo XR (QL, ST) Altoprev (QL, ST) Flolipid (PA) Zypitamag (QL, ST) Bevyxxa (QL) Pradaxa (QL, ST) Savaysa (QL, ST) Kazano (QL, ST) Kombiglyze XR (QL, ST) Nesina (QL, ST) Onglyza (QL, ST) Oseni (QL, ST) Invokana (QL,ST) Invokamet (QL,ST) Invokamet XR (QL,ST) Segluromet (QL, ST) Steglatro (QL, ST) SGLT-2/DPP-4 INHIBITOR GLP-1 AGONISTS Glyxambi (QL,ST) Bydureon (QL, ST) Bydureon BCise (QL, ST) Byetta (QL, ST) Trulicity (QL,ST) Steglujan (QL, ST) Qtern (QL, ST) Adlyxin (QL, ST) Ozempic (QL, ST) Victoza (QL,ST) INSULINS, RAPID-ACTING Humalog (QL) Admelog (QL, ST) Afrezza (PA,QL) Apidra (QL, ST) Fiasp (QL, ST) Novolog (QL, ST) INSULINS, SHORT-ACTING Humulin (QL) Novolin (QL, ST) INSULINS, LONG-ACTING Lantus (QL) Levemir (QL) Toujeo (QL) Tresiba (QL) Basaglar (QL, ST) INSULIN (LONG-ACTING) AND GLP-1 AGONIST DIABETIC SUPPLIES ENDOCRINE ANDROGENS me-testosterone (PA) testosterone 1% gel (PA) testosterone cypionate (PA) testosterone enanthate (PA) Soliqua (QL, ST) Xultophy (QL, ST) Preferred Abbott diabetic supplies (Precision, FreeStyle, FreeStyle Neo brand) (QL) Abbott Freestyle Libre CGM (PA) Androgel (PA) All non-abbott diabetic supplies (e.g., Contour, Breeze, OneTouch brand) (QL, ST) Androderm (PA) Fortesta (PA) Natesto (PA) Testim (PA) Vogelxo (PA) Page 2
3 ESTROGENS estradiol patches (QL) estradiol/norethindrone estropipate medroxyprogesterone norethindrone ac-eth estradiol progesterone, micronized Combipatch (QL) Crinone Duavee Menest Premarin Premphase Prempro Cenestin Climara Pro (QL) Enjuvia Estring (QL) Femtrace Prefest Striant (PA) OSTEOPOROSIS AGENTS WEIGHT REDUCTION GASTROINTESTINAL IRRITABLE BOWEL &CONSTIPATION INFLAMMATORY BOWEL DISEASE AGENTS PANCREATIC ENZYMES alendronate (QL on solution) calcitonin ibandronate raloxifene (QL) risedronate (QL, ST) risedronate DR (QL, ST) phentermine phendimetrazine diethylpropion topiramate balsalazide disodium sulfasalazine Forteo (PA, QL) Tymlos (PA) Linzess (QL) Movantik (QL) Apriso Lialda Pentasa Creon Zenpep Binosto (QL, ST) Belviq (PA) Belviq XR (PA) Contrave (PA) Qsymia (PA) Saxenda (PA) Amitiza (ST, QL) Symproic (QL, ST) Trulance (QL, ST) Delzicol (ST) Dipentum (ST) Pancreaze Pertzye GENITOURINARY DRUGS TO TREAT IMPOTENCY sildenafil (QL) Viagra (QL) Cialis 2.5mg, 5mg (PA, QL) Cialis 10mg, 20mg (QL, ST) Levitra (QL, ST) Staxyn (QL, ST) Stendra (QL, ST) PAIN MANAGEMENT BUPRENORPHINE-CONTAINING PRODUCTS buprenorphine/naloxone (CU, QL) buprenorphine (PA, CU, QL) Suboxone film (CU, QL) Zubsolv (CU, QL) Belbuca (ST,QL) Bunavail (CU, QL) FENTANYL fentanyl citrate (QL) Abstral (PA) Fentora (PA) Lazanda (PA) Onsolis (PA) Subsys (PA) MORPHINE morphine sulfate ER (QL) Kadian (QL) RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS BETA-AGONISTS, SHORT-ACTING (SABA) INHALED CORTICOSTEROIDS (ICS) INHALED CORTICOSTEROID/LONG- ACTING BETA AGONIST (ICS/LABA) epinephrine autoinjector (QL) EpiPen (QL) Adrenaclick Auvi-Q (QL) ProAir HFA levalbuterol tartrate ProAir RespiClick Proventil HFA Ventolin HFA Xopenex HFA Arnuity Ellipta (QL) Flovent Diskus/HFA (QL) Qvar (QL) Qvar Redihaler (QL) Advair Diskus/HFA (QL) Breo Ellipta (QL) Dulera (QL) Symbicort (QL) Perforomist (QL) Serevent Diskus (QL) Striverdi Respimat (QL) Aerospan (QL, ST) Alvesco (QL, ST) Armonair RespiClick (QL, ST) Asmanex (QL, ST) Pulmicort (QL, ST) Airduo RespiClick (brand and authorized generic) INHALED LONG-ACTING BETA AGONIST (LABA) Arcapta (QL, ST) Brovana (QL) Foradil (QL, ST) INHALED LONG-ACTING Spiriva Handihaler (QL) Incruse Ellipta (QL, ST) Page 3
4 MUSCARINIC ANTAGONISTS (LAMA) Spiriva Respimat (QL) Lonhala Magnair (QL) Seebri Neohaler (QL, ST) Tudorza Pressair (QL, ST) INHALED LONG-ACTING MUSCARINIC ANTAGONISTS AND LONG-ACTING BETA AGONIST (LAMA/LABA) INHALED CORTICOSTEROID, LONG-ACTING MUSCARINIC ANTAGONIST, AND LONG-ACTING BETA AGONIST (ICS/LAMA/LABA) ANTI-LEUKOTRIENES SPECIALTY montelukast zafirlukast Anoro Ellipta (QL) Stiolto Respimat (QL) Trelegy Ellipta (QL) Bevespi Aerosphere (QL, ST) Utibron Neohaler (QL, ST) Zyflo (QL, ST) Zyflo CR (QL, ST) ANEMIA AGENTS Procrit (PA) Aranesp (PA) Epogen (PA) Mircera (PA) Retacrit (PA) AUTOIMMUNE AGENTS GROWTH HORMONES HEPATITIS C AGENTS Cosentyx (PA) Enbrel (PA) Humira (PA) Otezla (PA) Stelara (PA) Norditropin (PA) Omnitrope (PA) Epclusa (PA) Harvoni (PA) Mavyret (PA) Vosevi (PA) MULTIPLE SCLEROSIS AGENTS Glatopa (PA) Aubagio (PA) Avonex (PA) Copaxone (PA) Gilenya (PA) Plegridy (PA) Rebif (PA) Rebif Rebidose (PA) Tecfidera (PA) PCSK9 INHIBITORS Praluent (PA) Repatha (PA) Actemra (PA) Cimzia (PA) Inflectra (PA) Kevzara (PA) Kineret (PA) Olumiant (PA) Orencia (PA) Remicade (PA) Renflexis (PA) Siliq (PA) Simponi (PA) Simponi Aria (PA) Taltz (PA) Tremfya (PA) Xeljanz (PA) Xeljanz XR (PA) Genotropin (PA) Humatrope (PA) Nutropin (PA) Saizen (PA) Serostim (PA) Zomacton (PA) Zorbtive (PA) Daklinza (PA) Sovaldi (PA) Technivie (PA) Viekira Pak (PA) Viekira XR (PA) Zepatier (PA) Ampyra (PA) Betaseron (PA) Extavia (PA) Page 4
5 A recommended prescribing guideline may apply (denoted throughout the document using the following symbols): AGE Age Edit Coverage may depend on patient age. CU Concurrent Use Edit Coverage or lack thereof may depend upon concurrent use of another drug PA Prior Authorization Requires specific physician request process. QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period. ST Step Therapy Coverage depends on previous use of another drug Specialty Drugs: Coverage of specialty drugs may be limited to a preferred Specialty Pharmacy. Call Pharmacy Customer Service at for additional information. Page 5
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