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North Carolina Medicaid and NC Health Choice Preferred Drug List (PDL) Changes

Monday, July 1, 2019

Effective July 1, 2019, NC Medicaid will make changes to the North Carolina Medicaid and NC Health Choice Preferred Drug List.

Below is a quick summary (not a complete exhaustive list) of the changes.

ANALGESICS (OPIOID ANALGESIC, LONG ACTING)

  • Move tramadol ER tablet to Long Acting Opioid analgesic category (from short acting)
  • Move tramadol ER tablet to Preferred status from Non-Preferred

ANALGESICS (SHORT ACTING SCHEDULE II OPIOIDS)

  • Add Apadaz™ tablet to Non-Preferred status
  • Add Oxaydo® tablet to Non-Preferred status

ANALGESICS (SHORT ACTING SCHEDULE III-IV OPIOIDS / ANALGESIC COMBINATIONS)

  • Move tramadol ER tablet to Long Acting opioid analgesic category and move to Preferred status
  • Move Conzip® capsule to Long Acting opioid analgesic category and leave it as a Non-Preferred product

ANALGESICS (NEUROPATHIC PAIN)

  • Add ZTLido™ to Non-Preferred status with clinical criteria

ANTICONVULSANTS (SECOND GENERATION)

  • Add clobazam suspension / tablet to Non-Preferred status
  • Add Epidiolex® solution to Non-Preferred status with an exception made for children ≥ 2 years old with Lennox-Gastaut Syndrome or Dravet Syndrome

ANTI-INFECTIVES (NITROMIDAZOLES)

  • Add Firvanq™ to Non-Preferred status

ANTI-INFECTIVES (TETRACYCLINE DERIVATIVES)

  • Add Minocin® to Non-Preferred status
  • Add Nuzyra™ to Non-Preferred status

ANTI-INFECTIVES (ANTIFUNGALS)

  • Add Tolsura™ capsule to Non-Preferred status

ANTI-INFECTIVES - ANTIVIRALS (HEPATITIS B AGENTS)

  • Move Epivir® HBV Tablet / Solution to Non-Preferred status from Preferred status
  • Move lamivudine HBV tablet (generic for Epivir® HBV) to Preferred status from Non-Preferred status

ANTI-INFECTIVES - ANTIVIRALS (HEPATITIS C AGENTS)

  • Add sofobuvir-velpatasvir tablet (generic of Epclusa® tablet) to Preferred status for recipients with Hepatitis C, all genotypes with decompensated cirrhosis. Note that the same clinical criteria as branded Epclusa® tablet will apply to this product.
  • Move Epclusa® tablet to Non-Preferred status from Preferred status
  • Add ledipasvir-sofosbuvir (generic for Harvoni Epclusa® tablet tablet) to Non-Preferred status. The same clinical criteria as branded Harvoni apply to this generic version.

ANTI-INFECTIVES - ANTIVIRALS (INFLUENZA)

  • Remove amantadine capsule / solution (generic for Symmetrel®) from this PDL category
  • Add Xofluza™ to Non-Preferred status

ANTI-INFECTIVES (INHALED ANTIBIOTICS)

  • Add Arikayce® to Non-Preferred status

BEHAVIORAL HEALTH (ANTIHYPERKINESIS/ADHD)

  • Move clonidine ER tablet to Preferred status from Non-Preferred status. This move was made on 1/28/2019 due to recipient access issues from Kapvay® becoming a CMS non-rebateable product.
  • Move Dyanavel® XR suspension to Preferred status from Non-Preferred status

BEHAVIORAL HEALTH (ATYPICAL ANTIPSYCHOTICS- INJECTABLE LONG ACTING)

  • Add Aristada® Initio™ syringe to Preferred status
  • Move Perseris® syringe to Preferred status from Non-Preferred status

BEHAVIORAL HEALTH (ATYPICAL ANTIPSYCHOTICS – ORAL)

  • Add Abilify® MyCite® to Non-Preferred status

CARDIOVASCULAR (ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS)

  • Move Exforge® HCT to Non-Preferred status from Preferred status
  • Move amlodipine/valsartan/HCTZ tablet (generic for Exforge® HCT) to Preferred status from Non-Preferred status
  • Move Exforge® to Non-Preferred status from Preferred status

CARDIOVASCULAR (ANTI-ARRHYTHMICS)

  • Move dofetilide capsule (generic for Tikosyn® capsule) to Preferred status from Non-Preferred status

CARDIOVASCULAR (BETA BLOCKERS)

  • Add Tenormin® to Non-Preferred status
  • Add Kapspargo™ Sprinkle to Non-Preferred status, with an exemption for children < 12 years of age

CARDIOVASCULAR (BILE ACID SEQUESTRANTS)

  • Add colesevelam packet / tablet (generic for Welchol®) to Non-Preferred status

CARDIOVASCULAR (DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS)

  • Move nifedipine ER tablet (generic for Adalat CC® / Procardia XL®) to Preferred status from Non-Preferred status. This move was made 12/14/2018 due to product discontinuation of Afeditab CR® and Nifedical XL®.

CENTRAL NERVOUS SYSTEM (ANTIMIGRAINE AGENTS - CGRP BLOCKERS/MODULATORS)

  • Add CGRP Blockers/Modulators as a new PDL subcategory under Antimigraine Agents. All drugs in this category have clinical criteria for coverage.
  • Add Aimovig™ and Emgality® to Preferred status
  • Add Ajovy™ to Non-Preferred status

CENTRAL NERVOUS SYSTEM (ANTIPARKINSON AND RESTLESS LEG SYNDROME AGENTS)

  • Add Osmolex™ ER tablet to Non-Preferred status with clinical criteria for coverage

CENTRAL NERVOUS SYSTEM (MULTIPLE SCLEROSIS)

  • Add dalfampridine ER tablet (generic of Ampyra® tablet) to Preferred status

ENDOCRINOLOGY (HYPOGLYCEMICS- INJECTABLE, RAPID ACTING INSULIN)

  • Add Humalog® U-100 KwikPen® / vial to Preferred status. This is a clarification / FYI only; as this has been processing this way.
  • Add Humalog® U-100 cartridge / U-100 Junior KwikPen® to Non-Preferred status. This is a clarification / FYI only; as this has been processing this way.
  • Add Humalog® U-200 KwikPen® to Non-Preferred status. This is a clarification / FYI only; as this has been processing this way.

ENDOCRINOLOGY - HYPOGLYCEMICS (INJECTABLE, SHORT ACTING INSULIN)

  • Add Humulin® R U500 vial to Preferred status. This is a clarification / FYI only; as this has been processing this way.

ENDOCRINOLOGY – HYPOGLYCEMICS (INJECTABLE, LONG ACTING INSULIN)

  • Add Toujeo® Max SoloStar® to Non-Preferred status.

ENDOCRINOLOGY – HYPOGLYCEMICS (INJECTABLE, PREMIXED 70/30 COMBINATION INSULIN)

  • Add Novolin® 70/30 FlexPen® to Non-Preferred status.
  • Move Humulin® 70/30 KwikPen® to Preferred status from Non-Preferred status

GASTROINTESTINAL (ANTIEMETIC-ANTIVERTIGO AGENTS)

  • Add Compro® rectal to Non-Preferred status
  • Move promethazine ampule / vial (generic for Phenergan®) to Preferred status from Non-Preferred status

GASTROINTESTINAL (PROTON PUMP INHIBITORS)

  • Move lansoprazole Rx capsule (generic for Prevacid® Rx capsule) to Preferred status from Non-Preferred status

GASTROINTESTINAL (ULCERATIVE COLITIS – ORAL)

  • Add budesonide ER tablet (generic for Uceris®) to Non-Preferred status

GASTROINTESTINAL (ULCERATIVE COLITIS – RECTAL)

  • Add mesalamine suppository (generic for Canasa®) to Non-Preferred status

GENITOURINARY / RENAL (BENIGN PROSTATIC HYPERPLASIA TREATMENTS)

  • Add silodosin capsule (generic for Rapaflo®) to Non-Preferred status
  • Add tadalafil tablet (generic for Cialis®) to Non-Preferred status. Clinical criteria apply for coverage.

HEMATOLOGIC (COLONY STIMULATING FACTORS)

  • Add Udenyca™ Syringe to Non-Preferred status

HEMATOLOGIC (HEMATOPOIETIC AGENTS)

  • Add Retacrit® vial to Non-Preferred status

HEMATOLOGIC (THROMBOPOIESIS STIMULATING AGENTS)

  • Add Promacta® suspension to Preferred status
  • Add Tavalisse™ tablet to Non-Preferred status

OPHTHALMIC (ANTIBIOTICS)

  • Move Neo-Polycin® ophthalmic ointment (branded generic for Neosporin® Ophthalmic Ointment) to Non-Preferred status from Non-Preferred status

OPHTHALMIC (ANTI-INFLAMMATORY)

  • Add Bromsite™ solution to Non-Preferred status
  • Add Dexycu™ vial to Non-Preferred status
  • Add Inveltys™ drops to Non-Preferred status
  • Add Yutiq™ implant to Non-Preferred status

OPHTHALMIC (ANTI-INFLAMMATORY / IMMUNOMODULATOR)

  • Add Cequa™ drops to Non-Preferred status

OPHTHALMIC (CARBONIC ANHYDRASE INHIBITORS / COMBINATIONS)

  • Add dorzolamide/timolol PF drops (generic for Cosopt PF®) to Non-Preferred status

OPHTHALMIC (PROSTAGLANDIN AGONISTS)

  • Add Xelpros® drops to Non-Preferred status

RESPIRATORY (BETA ADRENERGIC HANDHELD, SHORT ACTING)

  • Add albuterol HFA inhaler (generic for Proair® HFA inhaler) to Non-Preferred status
  • Add albuterol HFA inhaler (generic for Ventolin® HFA inhaler) to Non-Preferred status
  • Add levalbuterol HFA inhaler (generic for Xopenex® HFA inhaler) to Non-Preferred status

RESPIRATORY (ORALLY INHALED ANTICHOLINERGICS / COPD AGENTS)

  • Add Yulpelri™ solution to Non-Preferred status

RESPIRATORY (CORTICOSTEROID COMBINATIONS)

  • Add fluticasone/salmeterol inhaler (generic for Advair® Diskus®) to Non-Preferred status
  • Add Wixela™ Inhub™ to Non-Preferred status

RESPIRATORY (INTRANASAL RHINITIS AGENTS)

The panel approves the PDL proposal for INTRANASAL RHINITIS AGENTS with the following changes:

  • Add Sinuva™ implant to Non-Preferred status

TOPICALS (ACNE AGENTS)

  • Add adapalene solution to Non-Preferred status
  • Add clindamycin/benzoyl peroxide with pump (generic for Acanya®) to non-Preferred status
  • Add Plixda® swabs to Non-Preferred status

TOPICALS (NSAIDS)

The panel approves the PDL proposal for NSAIDS with the following changes:

  • Add DermacinRx® Lexitral PharmaPak® to Non-Preferred status

TOPICALS (ANTIFUNGALS)

  • Add miconazole/zinc oxide/petrolatum ointment (generic for Vusion®) to Non-Preferred status with clinical criteria to match the branded Vusion® product

TOPICALS (ANTIPARASITICS)

  • Add Crotan™ lotion to Non-Preferred status

TOPICALS (IMMUNOMODULATORS - ATOPIC DERMATITIS)

  • Add pimecrolimus cream (generic for Elidel®) to Non-Preferred status

TOPICALS (IMMUNOMODULATORS – IMIDAZOQUINOLINAMINES)

The panel approves the PDL proposal for TOPICAL IMMUNOMODULATORS, IMIDAZOQUINOLINAMINES with the following changes:

  • Add Veregen® ointment to Non-Preferred status

TOPICALS (ROSACEA AGENTS)

  • Add azelaic acid gel (generic for Finacea® gel) to Non-Preferred status

TOPICALS (STEROIDS - HIGH POTENCY)

  • Add desoximetasone spray (generic for Topicort®) to Non-Preferred status

TOPICALS (STEROIDS - VERY HIGH POTENCY)

  • Add Bryhali™ lotion to Non-Preferred status
  • Add halobetasol propionate foam (generic for Lexette®) to Non-Preferred status
  • Add Lexette® foam to Non-Preferred status

MISCELLANEOUS (EPINEPHRINE - SELF INJECTED)

Clarifying that all self-injected epinephrine products have quantity limits that apply. This has been the case, but it has not been listed on the PDL document.

  • Add Symjepi™ to Non-Preferred status

MISCELLANEOUS (PROGESTATIONAL AGENTS)

  • Move hydroxyprogesterone caproate injection single dose vial to Preferred status from Non-Preferred status
  • Move Makena auto injector to Preferred status from Non-Preferred status

Both of these PDL updates were made for access reasons on 12/27/2018 due to Makena vials being on manufacturer backorder.

MISCELLANEOUS (IMMUNOMODULATORS – SYSTEMIC)

  • Add Ilumya® injection to Non-Preferred status
  • Add Olumiant® tablet to Non-Preferred status
Author: 
GDIT, (800) 688-6696