An Information Service of the Division of Medical Assistance. North Carolina Medicaid Pharmacy Newsletter. Number 237 December In This Issue...

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1 An Information Service of the Division of Medical Assistance North Carolina Medicaid Pharmacy Newsletter Number 237 December 2014 In This Issue... Prescribers Not Enrolled in Medicaid - Institutional NPI Clarification Lock-In Program Updates Brand Adderall Immediate Release Pharmacy Pricing N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes Updates Posted to Pharmacy Prior Approval Clinical Criteria and Forms 72-Hour Emergency Supply Available for Pharmacy Prior Authorization Drugs Updated Federal Upper Limit Reimbursement List Published by CSC, fiscal agent for the North Carolina Medicaid Program

2 Prescribers Not Enrolled in Medicaid - Institutional NPI Clarification The Affordable Care Act established a new rule that prohibits Medicaid and Children s Health Insurance Programs [such as N.C. Health Choice (NCHC)] from paying for prescriptions written by prescribers who are not enrolled in Medicaid and NCHC programs. If your system will allow it, the Division of Medical Assistance (DMA) is allowing pharmacy providers to use an institutional NPI for those providers who are not enrolled but are working for an enrolled institution. DMA is aware of this issue for patients and prescriptions, especially in our border communities servicing out of state hospitals. Lock-In Program Updates The beneficiary lock-in program operates in accordance with federal and state laws for the control of beneficiary overutilization of Medicaid benefits. Beneficiaries identified for the lock-in program are restricted to a single prescriber and pharmacy in order to obtain opioid analgesics, benzodiazepines, and certain anxiolytics covered through the Medicaid Outpatient Pharmacy Program. Criteria for inclusion in this program can be found at The first beneficiaries using NC Tracks were identified in December, 2014 and will be getting notification letters in January, Providers with whom the beneficiary will be locked in will be notified in February, These beneficiaries will be locked into one prescriber and one pharmacy for one year for all benzodiazepine and opioid medications beginning March 1, Providers who have questions should call CSC at N.C. Medicaid will reimburse an enrolled Medicaid pharmacy for a four-day supply of a prescription dispensed to a beneficiary locked into a different pharmacy and prescriber in response to an emergency situation. The system will require the pharmacy provider to place a 3 in the Level of Service Field in order to override the lock-in edit. The provider will be paid only for the drug cost, and the beneficiary will be responsible for the appropriate copayment. One emergency occurrence will be reimbursed per beneficiary during the one year lock-in period. Records of dispensing of emergency supply medications are subject to review by Program Integrity. Paid quantities for more than a four-day supply are subject to recoupment. 2

3 Brand Adderall Immediate Release Brand Adderall IR is a preferred product and will remain preferred until the next PDL Panel meeting in The costs to the state on this product have changed because this product is no longer considered a brand drug by the Federal government. On February 1, 2015 DMA will place a State Maximum Allowable Cost (SMAC) on all Adderall IR products. Please utilize any remaining inventory of brand Adderall IR before February 1, A DAW 1 code will not work after this date because the product is considered to be generic. Pharmacy Pricing Effective with a date of service of January 1, 2015, DMA will make the following changes to pricing of medications per Session Law , 1. Medications will be paid at lessor of the National Average Drug Acquisition Cost, (NADAC), or Usual and Customary, (U&C), price submitted by the pharmacy. NADAC is the Center for Medicare and Medicaid Services, (CMS), survey on drug prices, Topics/Benefits/Prescription-Drugs/Survey-of-Retail-Prices.html. 2. In the event that a price is not found on NADAC, the product will be priced at the lessor of Wholesale Acquisition Cost, (WAC), plus 2.7% for non-specialty medications, or State Maximum Allowable Cost, (SMAC), or U&C. Specialty drugs, product that costs more than $1500 for a month s supply, will be priced at lessor of WAC + 1%, or SMAC, or U&C. 3. Dispensing Fees will change to the following: $13 for non-preferred brand product listed on the PDL and $14 for all other medications dispensed. 4. Federal Upper Limits, (FULs), will no longer be used in the pricing logic. For generic products that you use a DAW 1 in order to be paid enough will no longer be allowed and will pay according to the pricing explained above. FULs may return if/when CMS updates the pricing and give guidance on how it should be used with NADAC. This pricing model IS NOT programed at this time. Although this is effective, payments will be made according to these parameters once DMA has approval from the Centers for Medicare & Medicaid Services (CMS) and programming is completed in NCTracks. 3

4 N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes Effective with an estimated date of service of January 1, 2015 DMA will make changes to the N.C. Medicaid and NCHC Preferred Drug List (PDL). Please visit for the new PDL. In addition, the preferred brands with non-preferred generic equivalents will be updated and are listed in the chart below: Brand Name Accolate Adderall XR Aldara Alphagan P Astelin/Astepro Bactroban Benzaclin Cardizem LA Catapress-TTS Cedax Cymbalta Derma-Smoothe-FS Desoxyn Dexedrine Spansules Diastat/Diastat Accudial Differin Diovan Diovan HCT Duetact Epivir HBV Entocort EC Epi-Pen Exforge Exelon Focalin / Focalin XR Gabitril Gris-Peg Hepsera Kadian ER Lovenox Metadate CD Methylin Solution Metrogel Vaginal Natroba Niaspan ER Opana ER Prandin Generic Name Zafirlukast Amphetamine Salt Combo ER Imiquimod Brimonidine Azelastine Hydrochloride Mupirocin Clindamycin/Benzoyl Peroxide Matzim LA Clonidine Patches Ceftibuten Duloxetine Fluocinolone 0.01% Oil Methamphetamine Dextroamphetamine Diazepam Rectal Adapalene Valsartan Valsartan / Hydrochlorothiazide Pioglitazone / Glimepiride Lamivudine HBV Budesonide Epinephrine Amlodipine / Valsartan Rivastigmine Dexmethylphenidate Tiagabine Griseofulvin Ultramicrosize Adefovir Morphine Sulfate ER Enoxaparin Methylphenidate CD Methylphenidate Solution Metronidazole Gel Vaginal Spinosad Niacin ER Oxymorphone ER Repaglinide 4

5 Brand Name Generic Name PrevPac Lansoprazole / Amoxicillin / Clarithromycin Provigil Modafinil Pulmicort 0.25mg/2ml, Budesonide 0.25mg/2ml, 0.5mg/2ml 0.5mg/2ml Ritalin LA Methylphenidate ER Symbyax Olanzapine / Fluoxetine Tobradex Suspension Tobramycin/Dexamethasone Susp Toprol XL Metoprolol Succinate Travatan Travoprost Verelan PM Verapamil ER PM Zovirax Ointment Acyclovir Ointment Updates Posted to Pharmacy Prior Approval Clinical Criteria and Forms Pharmacy Prior Approval (PA) clinical criteria for Triptans and Narcotic Analgesics have been updated on the NCTracks Provider Portal under the Pharmacy Services webpage at In addition, the prior approval clinical criteria for Leukotrienes, along with the prior approval form, have been removed. 72-Hour Emergency Supply Available for Pharmacy Prior Authorization Drugs Pharmacy providers are encouraged to use the 72-hour emergency supply allowed for drugs requiring prior authorization. Federal law requires that this emergency supply be available to Medicaid recipients for drugs requiring prior authorization. [Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)]. Use of this emergency supply will ensure access to medically necessary medications. The system will bypass the prior authorization requirement if an emergency supply is indicated. A "3" in the Level of Service field (418-DI) should be used to indicate that the transaction is an emergency fill. Please Note: Co-payments will apply and only the drug cost will be reimbursed. There is no limit to the number of times the emergency supply can be used. Updated Federal Upper Limit Reimbursement List Certain drugs have been identified for which the Federal Upper Limit (FUL) reimbursement rate does not cover the cost of the drug. Medicaid pharmacy programs are required to reference this reimbursement information when pricing drug claims. In order to receive adequate reimbursement, pharmacy providers may use the DAW1 override to override the FUL reimbursement rate for the drugs listed on the FUL list until the FUL rate has been adjusted to adequately cover the cost of the drug. 5

6 As indicated in previous communications, use of the DAW1 override code is being monitored. A claim submitted for more than the State Maximum Allowable Cost (SMAC) rate on file may lead to an identifiable overpayment. Any difference between the SMAC rate on file for the date of service and the actual rate applied to the claim (if higher) may be considered an overpayment and subject to recoupment. NDC NAME ACETYLCYSTEI 200 MG VIAL ROXANE ALBUTEROL SULF 4MG TAB MUTUAL ALCLOMETASONE 0.05% CREAM TARO ALCLOMETASONE 0.05% CRM/ TARO ALCLOMETASONE DIPR 0.05% CRM/FOUGERA ALCLOMETASONE DIPR 0.05% CRM/FOUGERA ALCLOMETASONE DIPR 0.05% CRM/FOUGERA ALCLOMETASONE DIPR 0.05% CRM/GLENMARK ALCLOMETASONE DIPR 0.05% CRM/GLENMARK ALCLOMETASONE DIPR 0.05% CRM/GLENMARK ALCLOMETASONE DIPR 0.05% CRM/TARO AMITRIPTYLINE 150MG TAB/QUALITEST AMITRIPTYLINE 150MG TAB/SANDOZ AMITRIPTYLINE 25MG TAB/QUALITEST AMITRIPTYLINE 25MG TAB/QUALITEST AMITRIPTYLINE 25MG TAB/SANDOZ AMITRIPTYLINE 25MG TAB/SANDOZ AMITRIPTYLINE 50MG TAB/QUALITEST AMITRIPTYLINE 50MG TAB/QUALITEST AMITRIPTYLINE 50MG TAB/SANDOZ AMITRIPTYLINE 50MG TAB/SANDOZ AMITRIPTYLINE 75MG TAB/QUALITEST AMITRIPTYLINE 75MG TAB/SANDOZ AMITRIPTYLINE HCL 10 MG TAB MYLAN AMITRIPTYLINE HCL 10 MG TAB MYLAN AMITRIPTYLINE HCL 10 MG TAB MYLAN AMITRIPTYLINE HCL 10 MG TAB QUALITEST AMITRIPTYLINE HCL 10 MG TAB QUALITEST AMITRIPTYLINE HCL 10 MG TAB QUALITEST AMITRIPTYLINE HCL 10 MG TAB QUALITEST AMITRIPTYLINE HCL 10 MG TAB SANDOZ AMITRIPTYLINE HCL 10 MG TAB SANDOZ AMITRIPTYLINE HCL 100 MG TAB MYLAN AMITRIPTYLINE HCL 100 MG TAB MYLAN 6

7 AMITRIPTYLINE HCL 100 MG TAB QUALITEST AMITRIPTYLINE HCL 100 MG TAB QUALITEST AMITRIPTYLINE HCL 100 MG TAB SANDOZ ANAGRLIDE 0.5MG CAPS/TEVA ANAGRLIDE 1MG CAPS/TEVA BACLOFEN 10 MG TAB UPSHER SMITH BACLOFEN 10 MG TAB UPSHER SMITH BACLOFEN 10 MG TAB UPSHER SMITH BACLOFEN 10MG TAB/UPSHIRE SMITH BACLOFEN 10MG TABLET/LANNETT BACLOFEN 10MG TABLET/LANNETT BACLOFEN 10MG TABLET/MAJOR BACLOFEN 10MG TABLET/MCKESSON BACLOFEN 10MG TABLET/MYLAN BACLOFEN 10MG TABLET/MYLAN BACLOFEN 10MG TABLET/TEVA BACLOFEN 10MG TABLET/TEVA BACLOFEN 20 MG TAB UPSHER SMITH BACLOFEN 20 MG TAB UPSHER SMITH BACLOFEN 20 MG TAB UPSHER SMITH BACLOFEN 20MG TABLET UPSHIRE SMITH BENAZAPRIL/HCTZ 20/25MG TAB MYLAN BENAZEPRIL-HCTZ MG TAB MYLAN BENAZEPRIL-HCTZ MG TAB RISING BENAZEPRIL-HCTZ MG TAB SANDOZ BENAZEPRIL-HCTZ MG TAB MYLAN BENAZEPRIL-HCTZ MG TAB RISING BENAZEPRIL-HCTZ MG TAB SANDOZ BENAZEPRIL-HCTZ MG TAB RISING BENAZEPRIL-HCTZ MG TAB SANDOZ BENAZEPRIL-HCTZ MG TAB MYLAN BENAZEPRIL-HCTZ MG TAB SANDOZ BENZTROPINE 0.5MG TAB/AHP BENZTROPINE 0.5MG TAB/AHP BENZTROPINE 0.5MG TAB/BAYSHORE BENZTROPINE 0.5MG TAB/BAYSHORE BENZTROPINE 0.5MG TAB/CAMBER BENZTROPINE 0.5MG TAB/UPSHIRE SMITH BENZTROPINE 1MG TAB/AHP BENZTROPINE 1MG TAB/AHP BENZTROPINE 1MG TAB/BAYSHORE 7

8 BENZTROPINE 1MG TAB/BAYSHORE BENZTROPINE 1MG TAB/CAMBER BENZTROPINE 1MG TAB/CAMBER BENZTROPINE 1MG TAB/UPSHIRE SMITH BENZTROPINE 1MG TAB/UPSHIRE SMITH BENZTROPINE 2MG TAB/AHP BENZTROPINE 2MG TAB/AHP BENZTROPINE 2MG TAB/BAYSHORE BENZTROPINE 2MG TAB/BAYSHORE BENZTROPINE 2MG TAB/CAMBER BENZTROPINE 2MG TAB/CAMBER BENZTROPINE 2MG TAB/UPSHIRE SMITH BENZTROPINE 2MG TAB/UPSHIRE SMITH BETAMETH DIP 0.05 % LOT PERRIGO BETAMETHASONE DIP 0.05 % CRM SANDOZ BETAMETHASONE DIP 0.05 % CRM SANDOZ BETAMETHASONE VAL 0.1 % CREAM ACTAVIS BETAMETHASONE VAL 0.1 % CRM SANDOZ BETAMETHASONE VAL 0.1% CREAM SANDOZ BUMETANIDE 1 MG TABLET TEVA BUMETANIDE 1 MG TABLET TEVA CAPTOPRIL 100MG TAB/LEGACY CAPTOPRIL 100MG TAB/MYLAN CAPTOPRIL 100MG TAB/SANDOZ CAPTOPRIL 100MG TAB/WEST-WARD CAPTOPRIL 100MG TAB/WOCKHARDT CAPTOPRIL 12.5MG TAB WOCKHARDT CAPTOPRIL 12.5MG TAB/LEGACY CAPTOPRIL 12.5MG TAB/MAJOR CAPTOPRIL 12.5MG TAB/MYLAN CAPTOPRIL 12.5MG TAB/MYLAN CAPTOPRIL 12.5MG TAB/MYLAN CAPTOPRIL 12.5MG TAB/MYLAN CAPTOPRIL 12.5MG TAB/WEST-WARD CAPTOPRIL 12.5MG TAB/WEST-WARD CAPTOPRIL 12.5MG TAB/WOCKHARDT CAPTOPRIL 25MG TAB/LEGACY CAPTOPRIL 25MG TAB/MAJOR CAPTOPRIL 25MG TAB/MYLAN CAPTOPRIL 25MG TAB/MYLAN CAPTOPRIL 25MG TAB/MYLAN 8

9 CAPTOPRIL 25MG TAB/MYLAN CAPTOPRIL 25MG TAB/WEST-WARD CAPTOPRIL 25MG TAB/WEST-WARD CAPTOPRIL 25MG TAB/WOCKHARDT CAPTOPRIL 25MG TAB/WOCKHARDT CARBAMAZEPINE 100 MG SUS TARO CARBAMAZEPINE 100 MG TAB CHEW GSMS CARBAMAZEPINE 100 MG TAB CHEW MYLAN CARBAMAZEPINE 100 MG TAB CHEW MYLAN CARBAMAZEPINE 100 MG TAB CHEW TARO CARBAMAZEPINE 100 MG TAB CHEW TARO CARBAMAZEPINE 100 MG/5 ML SUSP MORTON GROVE CARBAMAZEPINE 200 MG TAB AHP CARBAMAZEPINE 200 MG TAB MYLAN CARBAMAZEPINE 200 MG TAB TARO CARBAMAZEPINE 200 MG TAB TARO CARBAMAZEPINE 200 MG TAB UPSHER SMITH CARBAMAZEPINE 200 MG TABLET APOTEX CARBAMAZEPINE 200 MG TABLET APOTEX CARISOPRODOL ASA MG TAB SANDOZ CARISOPRODOL ASA MG TAB SANDOZ CEFUROXIME AXETIL 500 MG TAB AUROBINDO CEFUROXIME AXETIL 500 MG TAB AUROBINDO CEFUROXIME AXETIL 500 MG TAB AUROBINDO CEFUROXIME AXETIL 500 MG TAB AUROBINDO CEFUROXIME AXETIL 500 MG TAB LUPIN CEFUROXIME AXETIL 500 MG TAB LUPIN CHOLESTYRAMINE SUCR 4 G PWD PAR CHOLESTYRAMINE SUCR 4 G PWD SANDOZ CHOLESTYRAMN 4 G PWD UPSHER SMITH CIMETIDINE 200MG/MYLAN CIMETIDINE 800MG/MYLAN CIMETIDINE 800MG/TEVA CLARITHROMYCIN 250 MG TAB SANDOZ CLARITHROMYCIN 500 MG TAB ROXANE CLARITHROMYCIN 500 MG TAB SANDOZ CLARITHROMYCIN 500 MG TAB WOCKHARDT CLARITHROMYCIN 500 MG TAB ZYDUS CLINDAMY PHOS 1 % GEL GRN STONE CLINDAMY PHOS 1 % GEL GRN STONE CLINDAMY PHOS 1 % SOL GRN STONE 9

10 CLINDAMYCIN 1 % SOLN GREENSTONE CLINDAMYCIN 1% LOTION GRN STONE CLINDAMYCIN PHOS 1 % GEL SANDOZ CLINDAMYCIN PHOS 1 % GEL SANDOZ CLINDAMYCIN PHOSP 1% LOTION SANDOZ CLOBETASOL 0.05 % OINT TARO CLOBETASOL 0.05 %CRM HI-TECH CLOBETASOL 0.05 %CRM HI-TECH CLOBETASOL 0.05 %CRM HI-TECH CLOBETASOL 0.05 %CRM HI-TECH CLOBETASOL 0.05 %CRM HI-TECH CLOBETASOL 0.05% CREAM SANDOZ CLOBETASOL 0.05% CREAM SANDOZ CLOBETASOL 0.05% CREAM SANDOZ CLOBETASOL 0.05% CREAM SANDOZ CLOBETASOL 0.05% CREAM TARO CLOBETASOL 0.05% CREAM TARO CLOBETASOL 0.05% CREAM TARO CLOBETASOL 0.05% CREAM TARO CLOBETASOL 0.05% OINT SANDOZ CLOBETASOL 0.05% OINT SANDOZ CLOBETASOL 0.05% OINT SANDOZ CLOBETASOL 0.05% OINT SANDOZ CLOBETASOL 0.05% OINTMENT HI-TECH CLOBETASOL 0.05% OINTMENT HI-TECH CLOBETASOL 0.05% OINTMENT HI-TECH CLOBETASOL 0.05% OINTMENT HI-TECH CLOBETASOL 0.05% OINTMENT TARO CLOBETASOL 0.05% OINTMENT TARO CLOBETASOL 0.05% OINTMENT TARO CLOBETASOL EMOL 0.05% CRM/FOUGERA CLOBETASOL EMOL 0.05% CRM/FOUGERA CLOBETASOL EMOL 0.05% CRM/FOUGERA CLOBETASOL EMOL 0.05% CRM/HI-TECH CLOBETASOL EMOL 0.05% CRM/HI-TECH CLOBETASOL EMOL 0.05% CRM/HI-TECH CLOBETASOL EMOL 0.05% CRM/TARO CLOBETASOL EMOL 0.05% CRM/TARO CLOBETASOL EMOL 0.05% CRM/TARO CLOMIPRAMINE 25 MG CAPSULE SANDOZ CLOMIPRAMINE 25 MG CAPSULE TARO 10

11 CLOMIPRAMINE 50 MG CAPSULE MYLAN CLOMIPRAMINE 50 MG CAPSULE SANDOZ CLOMIPRAMINE 75 MG CAP TARO CLOMIPRAMINE HCL 25MG CAP MYLAN CLOMIPRAMINE HCL 25MG CAP TARO CLOMIPRAMINE HCL 50 MG CAP TARO CLOMIPRAMINE HCL 50 MG CAP TARO CLORAZEPATE 3.75 MG TABLET MYLAN CLOTRIMAZOLE 1 %-0.05% CRM TARO CLOTRIMAZOLE 1 %-0.05% CRM TARO CLOTRIMAZOLE 1% SOLUTION/TARO CLOTRIMAZOLE 1% SOLUTION/TEVA CLOTRIMAZOLE 1% SOLUTION/TEVA CLOTRIMAZOLE-BETAMETH LOT TARO CLOTRM BMETH 1 %-0.05% CRM ACTAVIS CLOTRM BMETH 1 %-0.05% CRM ACTAVIS CLOTRM BMETH 1 %-0.05% CRM SANDOZ CLOTRM BMETH 1 %-0.05% CRM SANDOZ CLOTRM BMETH 1 %-0.05% LOT SANDOZ D-AMPHET SULF 10 MG TAB BARR D-AMPHET SULF 10 MG TAB MALLINCKRODT DESONIDE 0.05 % CREAM - ACTAVIS DESONIDE 0.05 % CRM PERRIGO DESONIDE 0.05 % CRM PERRIGO DESONIDE 0.05 % LOT ACTAVIS DESONIDE 0.05 % LOT ACTAVIS DESONIDE 0.05 % LOT SANDOZ DESONIDE 0.05 % LOT SANDOZ DESONIDE 0.05 % OINT PERRIGO DESONIDE 0.05 %CRM TARO DESONIDE 0.05 %OINT PERRIGO DESONIDE 0.05% CRM 15GM TARO DESONIDE 0.05% OINT TARO DEXADRINE 10MG TAB/AMEDRA DEXTROAMPHETAMINE 10MG TAB/AUROBINDO DEXTROAMPHETAMINE 10MG TAB/COREPHARMA DEXTROAMPHETAMINE 10MG TAB/WILSHIRE DICYCLOMINE 20 MG TABLET ACTAVIS DIGIOXIN 0.125MG TAB GLOBAL PHARM DIGOX 0.125MG TAB LANNETT DIGOX 250MCG TABLET LANNETT 11

12 DIGOXIN 125 MCG TAB LANNETT CO DIGOXIN 250 MCG TAB LANNETT CO DIPHENOXYLATE-ATROP MG TAB GREENSTONE DIPHENOXYLATE-ATROP MG TAB GREENSTONE DIPHENOXYLATE-ATROP MG TAB MYLAN DIPHENOXYLATE-ATROP MG TAB MYLAN DIPHENOXYLATE-ATROP MG TAB MYLAN DIPHENOXYLATE-ATROP MG TAB MYLAN DIPHENOXYLATE-ATROP MG TAB MYLAN DIPHENOXYLATE-ATROP MG TAB PD-RX DOXAZOSIN MESYLATE 2 MG TAB APOTEX DOXAZOSIN MESYLATE 4 MG TAB APOTEX DOXEPIN 100 MG CAPSULE MYLAN DOXEPIN 100 MG CAPSULE MYLAN DOXEPIN 10MG CAPS/MYLAN DOXEPIN 10MG CAPS/MYLAN DOXEPIN 10MG CAPSULE MYLAN DOXEPIN 10MG CAPSULE MYLAN DOXEPIN 25 MG CAPSULE/MYLAN DOXEPIN 25 MG CAPSULE/MYLAN DOXEPIN 25 MG CAPSULE/MYLAN DOXEPIN 25 MG CAPSULE/MYLAN DOXEPIN 50 MG CAPSULE MYLAN DOXEPIN HCL 100 MG CAP MYLAN DOXEPIN HCL 100 MG CAP MYLAN DOXEPIN HCL 50 MG CAP MYLAN DOXEPIN HCL 75 MG CAP MYLAN DOXY HYCLATE 100 MG CAP ACTAVIS DOXY HYCLATE 100 MG CAP MAJOR DOXY HYCLATE 100 MG CAP WEST WARD DOXY HYCLATE 100 MG CAP WEST WARD DOXY HYCLATE 100 MG CAP WEST WARD DOXY HYCLATE 100 MG TAB ACTAVIS DOXY HYCLATE 100 MG TAB MUTUAL DOXY HYCLATE 100 MG TAB MUTUAL DOXY HYCLATE 100 MG TAB WEST WARD DOXY HYCLATE 100MG CAP MUTUAL DOXY HYCLATE 100MG CAP MUTUAL DOXY HYCLATE 50 MG CAP MUTUAL DOXY HYCLATE 50 MG CAP WEST WARD 12

13 DOXYCYCLINE 100MG TABS - BLU PHARMA DOXYCYCLINE HYC 100MG TAB WEST WARD DOXYCYCLINE HYCLATE 100 MG CAP ACTAVIS DOXYCYCLINE HYCLATE 100 MG CAP/DAVA DOXYCYCLINE HYCLATE 100 MG CAP/DAVA ENALAPRIL 10MG TAB/AHP ENALAPRIL 10MG TAB/AHP ENALAPRIL 10MG TAB/LEGACY ENALAPRIL 10MG TAB/MAJOR ENALAPRIL 10MG TAB/MYLAN ENALAPRIL 10MG TAB/MYLAN ENALAPRIL 10MG TAB/MYLAN ENALAPRIL 10MG TAB/MYLAN ENALAPRIL 10MG TAB/TARO ENALAPRIL 10MG TAB/TARO ENALAPRIL 10MG TAB/TEVA ENALAPRIL 10MG TAB/TEVA ENALAPRIL 10MG TAB/TEVA ENALAPRIL 10MG TAB/WOCKHARDT ENALAPRIL 10MG TAB/WOCKHARDT ENALAPRIL 10MG TAB/WOCKHARDT ENALAPRIL MA20 MG TAB EON ETODOLAC 200MG CAP/APOTEX ETODOLAC 200MG CAP/TARO FLUCONAZOLE 200 MG TABLET GLENMARK FLUCONAZOLE 200 MG TABLET IVAX FLUCONAZOLE 50MG TAB/BLUEPOINT FLUCONAZOLE 50MG TAB/CITRON FLUCONAZOLE 50MG TAB/GLENMARK FLUCONAZOLE 50MG TAB/GREENSTONE FLUCONAZOLE 50MG TAB/NORTHSTAR FLUCONAZOLE 50MG TAB/PACK FLUCONAZOLE 50MG TAB/PACK FLUCONAZOLE 50MG TAB/TEVA FLUCONAZOLE 50MG TAB/TEVA FLUOCINONIDE 0.05 % CRM TARO FLUOCINONIDE 0.05 % CRM TARO FLUOCINONIDE 0.05 % CRM TARO FLUOCINONIDE 0.05 % CRM TARO FLUOCINONIDE 0.05 % SOL SANDOZ FLUOCINONIDE 0.05 % SOL TARO 13

14 FLUOCINONIDE 0.05% CREAM TEVA FLUOCINONIDE 0.05% CRM/ACTAVIS FLUOCINONIDE 0.05% CRM/ACTAVIS FLUOCINONIDE 0.05% CRM/ACTAVIS FLUOCINONIDE 0.05% CRM/TEVA FLUOCINONIDE 0.05% CRM/TEVA FLUOCINONIDE E 0.05 % CRM TEVA FLUOCINONIDE E 0.05 % CRM TEVA FLURAZEPAM 30MG CAP/MYLAN FLURAZEPAM 30MG CAP/MYLAN GENTAMICIN 0.1% CREAM PERRIGO GENTAMICIN 0.1% OINT PERRIGO GENTAMICIN 0.1% OINT PERRIGO GENTAMICIN 0.3% EYE DROP SANDOZ GENTAMICIN SULF 0.1% CREAM PERRIGO HALOBETASOL PROP 0.05 % OINT G&M LABS HC BUTYRATE 0.1 % CRM TARO HC VALERATE 0.2 % CRM PERRIGO HC VALERATE 0.2 % CRM PERRIGO HC VALERATE 0.2 % CRM PERRIGO HC VALERATE 0.2 % CRM TARO HC VALERATE 0.2 % CRM TARO HC VALERATE 0.2 % CRM TARO HC VALERATE 0.2 % OINT TARO HC VALERATE 0.2 % OINT TARO HC VALERATE 0.2 % OINT TARO HCTZ PROPRANOLOL 25MG /80 MG TAB MYLAN HCTZ TRIAM 75 MG-50MG TAB SANDOZ HCTZ TRIAM 75 MG-50MG TAB SANDOZ HCTZ TRIAM75 MG-50TABMYLA HCTZ TRIAM75 MG-50TABMYLA HYDROCORTISONE BUTY 0.1% CREAM/ROUSES PT HYDROCORTISONE BUTY 0.1% CREAM/ROUSES PT HYDROCORTISONE BUTY 0.1% CREAM/TARO IBUPROFEN 400 MG TABLET AMNEAL ISOSORB DINI20 MG TAB SANDOZ ISOSORB DINI20 MG TAB SANDOZ ISOSORBIDE DINIT 5MG TAB/BLUEPOINT ISOSORBIDE DINIT 5MG TAB/BLUEPOINT ISOSORBIDE DINIT 5MG TAB/SANDOZ ISOSORBIDE DINIT 5MG TAB/SANDOZ 14

15 ISOSORBIDE DINIT 5MG TAB/WEST-WARD ISOSORBIDE DINIT 5MG TAB/WEST-WARD ISOSORBIDE DINITRATE 10MG TAB PAR ISOSORBIDE DINITRATE 10MG TAB PAR ISOSORBIDE DINITRATE 20MG TAB PAR ISOSORBIDE DINITRATE 20MG TAB PAR ISOSORBIDE DINITRATE 30MG TAB PAR ISOSORBIDE DINITRATE 5MG TAB PAR ISOSORBIDE DINITRATE 5MG TAB PAR KLOR-CON M10 TAB/SANDOZ KLOR-CON M10 TAB/SANDOZ KLOR-CON M10 TAB/SANDOZ KLOR-CON M10 TAB/SANDOZ LABETALOL 300 MG TAB ACTAVIS LABETALOL 300MG TAB/AHP LABETALOL 300MG TAB/AHP LABETALOL 300MG TAB/BLUEPOINT LABETALOL 300MG TAB/BLUEPOINT LABETALOL 300MG TAB/MAJOR LABETALOL 300MG TAB/PAR LABETALOL 300MG TAB/PAR LABETALOL 300MG TAB/SANDOZ LABETALOL 300MG TAB/SANDOZ LABETALOL 300MG TAB/TEVA LABETALOL HCL 100 MG TABLET ACTAVIS LEVOTHYROXINE 100 MCG TABLET LANNETT LEVOTHYROXINE 100 MCG TABLET LANNETT LEVOTHYROXINE 100 MCG TABLET MYLAN LEVOTHYROXINE 100 MCG TABLET MYLAN LEVOTHYROXINE 100 MCG TABLET MYLAN LEVOTHYROXINE 100 MCG TABLET MYLAN LEVOTHYROXINE 100 MCG TABLET SANDOZ LEVOTHYROXINE 100 MCG TABLET SANDOZ LEVOTHYROXINE 125 MCG TAB LANNETT LEVOTHYROXINE 125 MCG TAB LANNETT LEVOTHYROXINE 125 MCG TAB MYLAN LEVOTHYROXINE 125 MCG TAB MYLAN LEVOTHYROXINE 125 MCG TAB MYLAN LEVOTHYROXINE 125 MCG TAB MYLAN LEVOTHYROXINE 125 MCG TAB SANDOZ LEVOTHYROXINE 125 MCG TAB SANDOZ 15

16 LEVOTHYROXINE 25MCG TAB/LANNETT LEVOTHYROXINE 25MCG TAB/LANNETT LEVOTHYROXINE 25MCG TAB/MYLAN LEVOTHYROXINE 25MCG TAB/MYLAN LEVOTHYROXINE 50 MCG TABLET LANNETT LEVOTHYROXINE 50 MCG TABLET LANNETT LEVOTHYROXINE 50 MCG TABLET MYLAN LEVOTHYROXINE 50 MCG TABLET MYLAN LEVOTHYROXINE 50 MCG TABLET MYLAN LEVOTHYROXINE 50 MCG TABLET MYLAN LEVOTHYROXINE 50 MCG TABLET SANDOZ LEVOTHYROXINE 50 MCG TABLET SANDOZ LEVOTHYROXINE 75 MCG TABLET LANNETT LEVOTHYROXINE 75 MCG TABLET LANNETT LEVOTHYROXINE 75 MCG TABLET MYLAN LEVOTHYROXINE 75 MCG TABLET MYLAN LEVOTHYROXINE 75 MCG TABLET MYLAN LEVOTHYROXINE 75 MCG TABLET MYLAN LEVOTHYROXINE 75 MCG TABLET SANDOZ LEVOTHYROXINE 75 MCG TABLET SANDOZ LEVOTHYROXINE 88 MCG TAB LANNETT LEVOTHYROXINE 88 MCG TAB LANNETT LEVOTHYROXINE 88 MCG TAB MYLAN LEVOTHYROXINE 88 MCG TAB MYLAN LEVOTHYROXINE 88 MCG TAB SANDOZ METHAZOLAMDE 50 MG TAB FERA METHAZOLAMDE 50 MG TAB SANDOZ METHOTREXATE 2.5 MG TAB BARR METHOTREXATE 2.5 MG TAB BARR METHOTREXATE 2.5 MG TAB ROXANE METHOTREXATE 2.5 MG TAB ROXANE METHYLPHENIDATE 10MG TAB/AHP METHYLPHENIDATE 10MG TAB/UCB METHYLPHENIDATE 20MG TAB/AHP METHYLPHENIDATE 20MG TAB/UCB METHYLPHENIDATE 5MG TAB UCB METHYLPHENIDATE 5MG TAB/ACTAVIS METHYLPHENIDATE 5MG TAB/AHP METHYLPHN HCL 10 MG TAB ACTAVIS METHYLPHN HCL 10 MG TAB CARACO METHYLPHN HCL 10 MG TAB MALLINCKRODT 16

17 METHYLPHN HCL 10 MG TAB MALLINCKRODT METHYLPHN HCL 10 MG TAB SANDOZ METHYLPHN HCL 20 MG TAB ACTAVIS METHYLPHN HCL 20 MG TAB CARACO METHYLPHN HCL 20 MG TAB MALLINCKRODT METHYLPHN HCL 20 MG TAB SANDOZ METHYLPHN HCL 5 MG TAB CARACO METHYLPHN HCL 5 MG TAB MALLINCKRODT METHYLPHN HCL 5 MG TAB MALLINCKRODT METHYLPHN HCL 5 MG TAB SANDOZ METHYLPREDNISOL 4 MG TAB QUALITEST METHYLPREDNISOL 4 MG TAB QUALITEST METHYLPREDNISOLONE 4 MG TAB CADISTA METHYLTREXATE SODIUM 2.5 MG TAB DAVA METOLAZONE 10MG TAB/MYLAN METOLAZONE 10MG TAB/SANDOZ METOLAZONE 10MG TAB/UCB METRONIDAZOL 500 MG TAB ACTAVIS METRONIDAZOLE 0.75 % CRM HARRIS METRONIDAZOLE 0.75 % GEL TARO METRONIDAZOLE 0.75 % LOT SANDOZ METRONIDAZOLE 0.75% CREAM ACTAVIS METRONIDAZOLE 250 MG TAB PLIVA METRONIDAZOLE 250 MG TABLET ACTAVIS METRONIDAZOLE 500 MG TAB PLIVA METRONIDAZOLE 500 MG TAB PLIVA MOMETASONE 0.1 % CRM G&M LABS NADOLOL 20 MG TAB TEVA NADOLOL 20MG CAP SANDOZ NADOLOL 20MG TABLET MYLAN NADOLOL 40 MG TAB MYLAN NADOLOL 40 MG TAB SANDOZ NADOLOL 40 MG TAB TEVA NEO POL DEXA OINT SANDOZ NEO POLYMX HCL % SOL SANDOZ NEOMYC-POLYM-DEXAMET EYE OINT VALEANT NEOMYC-POLYM-DEXAMET EYE OINTM/PERRIGO NEOMYC-POLYM-GRAMICID EYE DROP/MONARCH NEOMYC-POLYM-GRAMICID EYE DROP/VALEANT NORTRPTYLINE HCL 25 MG CAP ACTAVIS NORTRPTYLINE HCL 25 MG CAP ACTAVIS 17

18 NORTRPTYLINE HCL 25 MG CAP ACTAVIS NYST TRIAMC CRM SANDOZ NYST TRIAMCI CRM SANDOZ NYST TRIAMCIN CRM TARO NYST TRIAMCIN CRM TARO NYST TRIAMCIN CRM TARO NYST TRIAMCIN OINT TARO NYST TRIAMCIN OINT TARO NYST TRIAMCIN OINT TARO NYSTATIN 100,000 UNIT/GM CRM SANDOZ NYSTATIN UNIT CREAM PERRIGO NYSTATIN /G CRM ACTAVIS NYSTATIN /G CRM ACTAVIS NYSTATIN /G CRM QUALITEST NYSTATIN /G CRM QUALITEST NYSTATIN /G CRM TARO NYSTATIN /G CRM TARO NYSTATIN /G OINT ACTAVIS NYSTATIN /G OINT ACTAVIS NYSTATIN /G OINT PERRIGO NYSTATIN /G OINT PERRIGO NYSTATIN-TRIAMC OINT 30GM/SANDOZ NYSTATIN-TRIAMCINOLONE OINT SANDOZ NYSTATIN-TRIAMCINOLONE OINT SANDOZ OXAPROZIN 600MG TAB TEVA OXAPROZIN 600MG TAB/CARACO OXAPROZIN 600MG TAB/CARACO OXAPROZIN 600MG TAB/DR. REDDY'S OXAPROZIN 600MG TAB/DR. REDDY'S OXAPROZIN 600MG TAB/GREENSTONE OXAPROZIN 600MG TAB/SANDOZ OXAPROZIN 600MG TAB/TEVA OXAZEPAM 10 MG CAP ACTAVIS OXAZEPAM 15 MG CAP ACTAVIS OXAZEPAM 15 MG CAPSULE SANDOZ OXYBUTYNIN 5 MG TABLET PLIVA OXYBUTYNIN 5MG TAB PLIVA OXYBUTYNIN 5MG TABLET UPSHIRE SMITH OXYBUTYNIN CHLORIDE 5MG TABLET QUALITEST OXYBUTYNIN CHLORIDE 5MG TABLET QUALITEST OXYBUTYNIN CHLORIDE 5MG TABLET QUALITEST 18

19 OXYBUTYNIN CHLORIDE 5MG TABLET QUALITEST OXYCODON HCL 20 MG/ML CONC GLENMARK OXYCODON HCL 20 MG/ML CONC LANNETT OXYCODON HCL 20 MG/ML CONC LANNETT OXYCODON HCL 20MG/ML CONC. VISTA OXYCODONE 5 MG CAPSULE MIDLOTHIAN LAB OXYCODONE 5 MG CAPSULE- GLENMARK OXYCODONE HCL 100MG/5ML SOLN/MIDLOTHIAN OXYCODONE HCL 100MG/5ML SOLN/ROXANNE OXYCODONE HCL 5 MG TAB AHP OXYCODONE HCL 5 MG TAB AHP OXYCODONE HCL 5 MG TAB ALVOGEN OXYCODONE HCL 5 MG TAB AUROBINDO OXYCODONE HCL 5 MG TAB KVK-TECH OXYCODONE HCL 5 MG TAB MALLINCKRODT OXYCODONE HCL 5 MG TAB MALLINCKRODT OXYCODONE HCL 5 MG TAB MALLINCKRODT OXYCODONE HCL 5 MG TAB MIDLOTHIAN LAB OXYCODONE HCL 5 MG TAB QUALITEST OXYCODONE HCL 5 MG TAB QUALITEST OXYCODONE HCL 5 MG TAB ZYDUS PHENADOZ 12.5 MG SUP ACTAVIS PHENADOZ 12.5MG SUP WATSON PHENADOZ 25 MG SUP WATSON PHENADOZ 25MG SUP ACTAVIS PIROXICAM 20 MG CAP NOSTRUM LAB PIROXICAM 20 MG CAP NOSTRUM LAB PIROXICAM 20 MG CAP TEVA PIROXICAM 20 MG CAP TEVA POTASSIUM CL ER 10 MEQ TAB ACTAVIS POTASSIUM CL ER 10MEQ TAB/AHP POTASSIUM CL ER 10MEQ TAB/AHP POTASSIUM CL ER 10MEQ TAB/MCKESSON POTASSIUM CL ER 10MEQ TAB/MCKESSON POTASSIUM CL ER 10MEQ TAB/SANDOZ POTASSIUM CL ER 10MEQ TAB/SANDOZ PRAVASTATIN 40MG TAB - TEVA PRAVASTATIN 40MG TABLET TEVA PREDNISOLONE 1% DROP SANDOZ PREDNISOLONE ACET 1 % DRP SANDOZ PREDNISOLONE ACET 1 % DRP SANDOZ 19

20 PREDNISONE 10 MG TABLET PREDNISONE 10 MG TABLET ROXANE PREDNISONE 20 MG TABLET ROXANE PROMETHAZINE 12.5 MG SUPPOS PERRIGO PROMETHEGAN 12.5 MG SUP G&M LABS PROMETHEGAN 25 MG SUPP.RECT - G & W LABS PROPRANOLOL 80MG SA 24HR CAP ROUSES POINT PROPRANOLOL ER 160 MG CAPS ROUSES POINT PROPRANOLOL ER 160 MG CAPSULE ACTAVIS PROPRANOLOL ER 160 MG CAPSULE ACTAVIS PROPRANOLOL ER 160 MG CAPSULE BRECKENRIDGE PROPRANOLOL ER 160 MG CAPSULE UPSHER SMITH PROPRANOLOL ER 160 MG CAPSULE UPSHER SMITH PROPRANOLOL ER 60 MG CAPS ROUSES POINT PROPRANOLOL ER 60 MG CAPSULE ACTAVIS PROPRANOLOL ER 60 MG CAPSULE ACTAVIS PROPRANOLOL ER 60 MG CAPSULE BRECKENRIDGE PROPRANOLOL ER 60 MG CAPSULE UPSHER SMITH PROPRANOLOL ER 60 MG CAPSULE UPSHER SMITH RANITIDINE 300MG TAB/AMNEAL RANITIDINE 300MG TAB/AMNEAL RANITIDINE 300MG TAB/AMNEAL RANITIDINE 300MG TAB/GELNMARK RANITIDINE 300MG TAB/GELNMARK RANITIDINE 300MG TAB/GELNMARK RANITIDINE 300MG TAB/SANDOZ RANITIDINE 300MG TAB/SANDOZ RANITIDINE 300MG TAB/TEVA RANITIDINE 300MG TAB/TEVA SILVER SULFA DIAZ 1 % CRM ACTAVIS SILVER SULFA DIAZ 1 % CRM ACTAVIS SILVER SULFA DIAZ 1 % CRM ACTAVIS SILVER SULFADIAZINE CREAM ASCEND SILVER SULFADIAZINE CREAM ASCEND SSD 1 % CRM DR. REDDY SSD 1 % CRM DR. REDDY SSD 1% CREAM DR.REDDY'S LAB SSD CREAM - DR. REDDY'S SULFACETA NA10 % DRP VALEANT SULFACETAMIDE NA 10 % DRP SANDOZ TETRACYCLINE 500MG CAPS/HERRITAGE 20

21 THIOTHIXENE 5 MG CAPS MYLAN THIOTHIXENE 5 MG CAPS MYLAN THIOTHIXENE 5 MG CAPS MYLAN TOBRAMYCIN SULF 0.3 % DRP SANDOZ TRETINOIN 0.025% CREAM/ACTAVIS TRETINOIN 0.025% CREAM/ACTAVIS TRETINOIN 0.025% CREAM/PERRIGO TRETINOIN 0.025% CREAM/PERRIGO TRETINOIN 0.025% CREAM/ROUSES POINT TRETINOIN 0.025% CREAM/ROUSES POINT TRIAMCIN ACET 0.1 % CRM PERRIGO TRIAMCIN ACET 0.1 % CRM PERRIGO TRIAMCIN ACET 0.1 % CRM PERRIGO TRIAMCIN ACET 0.1 % CRM TARO TRIAMCIN ACET 0.5 % CRM PERRIGO TRIAMCINOLOLNE ACET 0.1% CREAM ASCEND TRIAMCINOLONE 0.1% OINTMENT PERRIGO TRIAMCINOLONE ACET 0.025% CRM SANDOZ TRIAMCINOLONE ACET 0.025% CRM SANDOZ TRIAMCINOLONE ACET 0.1 % CRM SANDOZ TRIAMCINOLONE ACET 0.1 % CRM SANDOZ TRIAMCINOLONE ACET 0.1 % CRM SANDOZ TRIAMCINOLONE ACET 0.1 % OINT SANDOZ TRIAMCINOLONE ACET 0.1 % OINT SANDOZ TRIAMCINOLONE ACET 0.1 % OINT SANDOZ TRIAMCINOLONE ACET 0.5 % CRM SANDOZ TRIAZOLAM MG TABLET GREENSTONE TRIAZOLAM 0.25 MG TABLET ROXANE TRIHEXYPHENIDYL 5 MG TABLET PACK ZENZEDI 10MG TAB/ARBOR Electronic Cut-Off Schedule Checkwrite Schedule January 2, 2015 January 6, 2015 January 9, 2015 January 16, 2015 January 13, 2015 January 21, 2015 January 23, 2015 January 27, 2015 POS Claims must be transmitted and completed by 11:59 p.m. on the day of the electronic cut-off date to be included in the next checkwrite. 21

22 The 2015 checkwrite schedules can be found under Quick Links on the NCTracks Provider Portal home page. John Stancil, R.Ph. Director, Pharmacy and Ancillary Services Division of Medical Assistance NC Department of Health and Human Services Jason Swartz, R.Ph, MBA Outpatient Pharmacy Program Manager Division of Medical Assistance NC Department of Health and Human Services Sandra Terrell, RN Director of Clinical Policy Division of Medical Assistance NC Department of Health and Human Services Rick Paderick, R.Ph. Pharmacy Director NCTracks CSC Lori Landman Deputy Executive Account Director NCTracks CSC Paul Guthery Executive Account Director NCTracks CSC Robin Gary Cummings, M.D. Deputy Secretary for Health Services Director, Division of Medical Assistance Acting State Health Director NC Department of Health and Human Services Nancy Henley, MD Chief Medical Officer Division of Medical Assistance NC Department of Health and Human Services 22