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2005 North Carolina
Please bring this list
2005 Medco Health Solutions, Inc. All rights reserved.
Medco is a registered trademark of Medco Health Solutions, Inc.
If you have questions about your prescription drug benefit,
visit
www.medco.com or call Member Services.
WHAT IS A PREFERRED DRUG LIST? A preferred drug list is a list of medications covered by your prescription drug plan. The
North Carolina drug list has been compiled by a committee of North Carolina
physicians and pharmacists organized by the plan. It includes medications made by most pharmaceutical
manufacturers and for a variety of conditions.
Using preferred medications can help you save money on your prescriptions. When you use a medicationon the preferred list, your co-payment (for up to a 34-day supply) will be:
Generic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$10 Brand-name drugs (without a generic equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$25 Brand-name drugs (with a generic equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$35 Nonpreferred brand-name drugs and other drugs as determined
by the Pharmacy & Therapeutics Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$40
WHAT ARE MY CO-PAYMENTS?
(Up to a 34-day supply)
(35 – 68-day supply)
(69 –102-day supply)
equivalent)Brand-name drugs(with a generic
equivalent)Nonpreferred brand-name drugs and other drugs as
determined by the Pharmacy& Therapeutics Committee
WHY SHOULD I USE GENERIC DRUGS? All generic drugs are preferred medications. Ask your doctor to authorize generic substitution whenever
a generic alternative is available. You will save money using generic drugs, since the co-payment is $10
for a 34-day supply.
Generic drugs, like brand-name drugs, must meet established Food and Drug Administration (FDA) stan-dards of quality and purity to help ensure their safety and effectiveness. Generic versions have the exactsame active ingredients as their brand-name counterparts, and they are equal in strength and dosage.
Sometimes drug manufacturers use different inactive ingredients, such as fillers and dyes, to provide adrug’s shape, color, size, and taste.
By prescribing generics and preferred brand names, your doctor can help you save money. Remember tobring this list with you each time you visit your doctor.
Please note: This is not a complete list of preferred drugs. In some cases, the Plan may have certain
coverage limits. Some drugs require prior authorization or may be subject to quantity limits. Refer to
your benefit materials or call
1 800 336-5933 for specific coverage information. You can also refer
to
www.statehealthplan.state.nc.us for a complete preferred list. This list is subject to change.
The information herein was current at the time of printing and is subject to change.
THERAPEUTIC DRUG CATEGORIES
$35.00 Co-pay $35.00 Co-pay ANTINEOPLASTICS AND
IMMUNOSUPPRESSANTS
$35.00 Co-pay Miscellaneous
$10.00 Co-pay $10.00 Co-pay are covered under the Rx benefit,
$25.00 Co-pay $25.00 Co-pay BLOOD MODIFIERS
Beta-Blockers Beta and Alpha Blockers
$35.00 Co-pay $25.00 Co-pay $35.00 Co-pay Anticoagulants
Myasthenia Gravis
$25.00 Co-pay $10.00 Co-pay $10.00 Co-pay acebutolol
CENTRAL NERVOUS SYSTEM
$35.00 Co-pay $10.00 Co-pay Alzheimer’s Disease
$25.00 Co-pay Parkinson’s Disease
$25.00 Co-pay $25.00 Co-pay $10.00 Co-pay Blood Cell Formation
$35.00 Co-pay $25.00 Co-pay Analgesics
$10.00 Co-pay $25.00 Co-pay Platelet Aggregation Inhibitors
$10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay Calcium Channel Blockers
$35.00 Co-pay $35.00 Co-pay $10.00 Co-pay Miscellaneous
$10.00 Co-pay $25.00 Co-pay Seizures
$10.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $10.00 Co-pay $35 Co-pay $25.00 Co-pay CARDIOVASCULAR
$35.00 Co-pay $25.00 Co-pay ACE Inhibitors
$10.00 Co-pay Diuretics
$10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $35.00 Co-pay $35.00 Co-pay DERMATOLOGY
Alpha-Blockers
Acne Vulgaris
$10.00 Co-pay $10.00 Co-pay Lipid-Lowering Agents
$35.00 Co-pay $25.00 Co-pay $35.00 Co-pay Angiotensin II Receptor Blockers
$10.00 Co-pay $25.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay Migraine
Antiarrhythmics and
$25.00 Co-pay Cardiac Glycosides
$10.00 Co-pay $10.00 Co-pay $35.00 Co-pay Nitrates
$35.00 Co-pay $25.00 Co-pay $10.00 Co-pay Bacterial Infections
$10.00 Co-pay $25.00 Co-pay $25.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan
THERAPEUTIC DRUG CATEGORIES (CONT.)
$25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay Corticosteroids
$35.00 Co-pay Inflammatory Bowel Disease
$10.00 Co-pay $25.00 Co-pay $10.00 Co-pay $25.00 Co-pay $10.00 Co-pay EAR, NOSE & THROAT
$25.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay Pancreatic Enzymes
$25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay Growth Hormone
$40.00 Co-pay $35.00 Co-pay $25.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay Miscellaneous
$35.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay Depigmenting and
Repigmenting Agents
$25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $25.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay GASTROINTESTINAL
$25.00 Co-pay Diarrhea
$10.00 Co-pay INFECTIOUS DISEASES
$35.00 Co-pay $25.00 Co-pay Antibacterials
ENDOCRINOLOGY
$35.00 Co-pay $25.00 Co-pay Adrenal Corticosteroids
$10.00 Co-pay $10.00 Co-pay $10.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay Gastroesophageal Reflux
$25.00 Co-pay Disease (GERD)
$10.00 Co-pay $10.00 Co-pay $35.00 Co-pay Diabetes Mellitus
$25.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $10.00 Co-pay Gastrointestinal Spasm
$10.00 Co-pay $35.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan
THERAPEUTIC DRUG CATEGORIES (CONT.)
$35.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $25.00 Co-pay 30 mcg estrogen
Transdermal
$10.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $35.00 Co-pay $35.00 Co-pay
norgestrel/EE 0.3/30
$25.00 Co-pay Progestins
$10.00 Co-pay $10.00 Co-pay $35.00 Co-pay MUSCULOSKELETAL
$25.00 Co-pay $35.00 Co-pay Arthritis
$35.00 Co-pay Antifungals
35 mcg estrogen
$10.00 Co-pay $10.00 Co-pay $10.00 Co-pay Anti-Estrogens
$10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $35.00 Co-pay $35.00 Co-pay Infertility
Antivirals
$40.00 Co-pay $10.00 Co-pay 50 mcg estrogen
$10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay desogestrel/EE
$25.00 Co-pay $40.00 Co-pay $35.00 Co-pay Vaginal Infections
$40.00 Co-pay $25.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $25.00 Co-pay $10.00 Co-pay $35.00 Co-pay $25.00 Co-pay $25.00 Co-pay Progestin
$35.00 Co-pay $10.00 Co-pay $25.00 Co-pay Miscellaneous
$10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay OPHTHALMIC
$25.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $25.00 Co-pay Endometriosis
$35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay Anti-Inflammatories
$25.00 Co-pay $10.00 Co-pay Hormone Therapy/Menopause
$35.00 Co-pay $25.00 Co-pay $35.00 Co-pay Contraceptives
Miscellaneous
$10.00 Co-pay $10.00 Co-pay 20 mcg estrogen
$10.00 Co-pay $25.00 Co-pay $25.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan
THERAPEUTIC DRUG CATEGORIES (CONT.)
$25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $40.00 Co-pay SUPPLEMENTS
Bipolar Disorder
$35.00 Co-pay $35.00 Co-pay $10.00 Co-pay Potassium
$25.00 Co-pay $10.00 Co-pay RESPIRATORY DRUGS
Asthma/COPD
$35.00 Co-pay Infections
Depression
$10.00 Co-pay $10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $25.00 Co-pay $25.00 Co-pay Vitamins and Minerals
$35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $10.00 Co-pay UROLOGICAL
$35.00 Co-pay $35.00 Co-pay $25.00 Co-pay Symptomatic Benign
Prostatic Hypertrophy
Glaucoma
$10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $10.00 Co-pay $10.00 Co-pay Insomnia
$25.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay Miscellaneous
Narcolepsy
$10.00 Co-pay $10.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $10.00 Co-pay $25.00 Co-pay Miscellaneous
$10.00 Co-pay Obsessive Compulsive Disorder
$25.00 Co-pay $10.00 Co-pay $25.00 Co-pay Antitussives, Decongestants, and
$35.00 Co-pay $35.00 Co-pay Expectorants
$25.00 Co-pay $10.00 Co-pay PSYCHIATRIC
$35.00 Co-pay MISCELLANEOUS
$10.00 Co-pay Panic Disorder
Anaphylaxis Emergency
$10.00 Co-pay $25.00 Co-pay Hyperphosphatemia
$25.00 Co-pay $25.00 Co-pay $25.00 Co-pay $35.00 Co-pay $35.00 Co-pay $40.00 Co-pay $25.00 Co-pay Premenstrual Dysphoric Disorder
$25.00 Co-pay $25.00 Co-pay Attention Deficit Hyperactivity
$35.00 Co-pay Disorder
Psychosis
$10.00 Co-pay $10.00 Co-pay Smoking Deterrents
$10.00 Co-pay $35.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan
Source: http://www.uncg.edu/hrs/pdlist.pdf
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