Community Care of North Carolina (CCNC) & Physicians Advisory Group (PAG)

DRUGS OF CHOICE (DOC) LIST

More Details and Updated Versions May Be Downloaded at www.ncdoclist.com IMPORTANT NOTES ON USE OF THIS REFERENCE: The DOC List is a multi-payer convenience list. All medications listed on the DOC LIST are designated as preferred medications by NC Medicaid. DOC List medications are also designated as preferred or tier 1 by BCBS of NC, NC State Health Plan, and NC Health Choice or are otherwise unrestricted on those plans.

ANALGESICS
Short Acting Narcotics: fentanyl lozenges, oxycodone IR, morphine sulfate IR NSAIDs: diclofenac, ibuprofen**, meloxicam, naproxen** Other: tramadol**

** Includes combination products of the same generic drug

ANTI-INFECTIVES (ORAL)
Antifungals: fluconazole, nystatin Cephalosporins: cefdinir, cefprozil, cefuroxime Fluoroquinolones: ciprofloxacin IR tablet and susp Macrolides: azithromycin, clarithromycin Nitromidazoles: metronidazole

BEHAVIORAL HEALTH
ADHD: amphetamine salt combo, dexmethylphenidate, dextroamphetamine, methylphenidate Antidepressants: bupropion, citalopram, fluoxetine, mirtazepine, paroxetine, sertraline, trazodone, venlafaxine

CARDIOVASCULAR

** Includes combination products of the same generic drug

ACE Inhibitors: benazepril**, enalapril**, lisinopril** Alpha Blockers: doxazosin, terazosin Beta Blockers: atenolol**, metoprolol**, propranolol** Calcium Channel Blockers: amlodipine, diltiazem, nifedipine, verapamil Fibrates: gemfibrozil Statins & Zetia: lovastatin, pravastatin, simvastatin Version: Abbreviated DOC List September 2010

Community Care of North Carolina (CCNC) & Physicians Advisory Group (PAG)

DRUGS OF CHOICE (DOC) LIST

More Details and Updated Versions May Be Downloaded at www.ncdoclist.com

CENTRAL NERVOUS SYSTEM

Anticonvulsants: carbamazepine, divalproex, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, topiramate, valproic acid Sedative Hypnotics: temazepam, zolpidem Skeletal Muscle Relaxants: baclofen, carisoprodol, cyclobenzaprine, tizanidine Smoking Cessation: bupropion SR, nicotine gum, nicotine lozenge, nicotine patch Triptans: sumatriptan

ENDOCRINE
Oral Hypoglycemics: glimepiride, glipizide, glyburide, metformin

GASTROINTESTINAL
Antiemetics: meclizine, odansetron, promethazine, prochlorperazine, scopolamine Histamine-2 Receptor Antagonists: famotidine, ranitidine Proton Pump Inhibitors: omeprazole, omeprazole OTC

GENITOURINARY
Alpha Blockers (for BPH): doxazosin, tamsulosin, terazosin Urinary Antispasmodics: oxybutinin IR tablet and syrup

MISCELLANEOUS
Antihyperuricemics (Gout): allopurinol Bisphosphonates: alendronate

OPHTHALMICS

** Includes combination products of the same generic drug

Anti-Infectives: ciprofloxacin, erythromycin, gentamicin, polymyxin B/trimethoprim, tobramycin Glaucoma: dorzolamide**, timolol**

Version: Abbreviated DOC List September 2010

Community Care of North Carolina (CCNC) & Physicians Advisory Group (PAG)

DRUGS OF CHOICE (DOC) LIST

More Details and Updated Versions May Be Downloaded at www.ncdoclist.com

OTICS
Anti-Infectives: neomycin/polymyxin B/hydrocortisone, ofloxacin

RESPIRATORY

** Includes combination products of the same generic drug

Anticholinergics (COPD): ipratropium (soln for inhalation) Inhaled Corticosteroids (and Combinations): budesonide (susp for inhalation), QVAR Nasal Corticosteroids: flunisolide, fluticasone Non-Sedating Antihistamines (and Combinations): cetirizine OTC tablets and syrup**, loratadine OTC** Short Acting Beta Agonists: albuterol (soln for inhalation) 2.5 mg/3 mL (0.083%) and 5 mg/1 mL (0.5%)

TOPICALS

** Includes combination products of the same generic drug

Antifungals: clotrimazole**, econazole, ketoconazole, nystatin** Anti-Infectives (Acne): benzoyl peroxide, erythromycin/benzoyl peroxide Anti-Infectives (Non-Acne): mupirocin ointment Anti-Inflammatories: betamethasone, clobetasol, fluocinonide, hydrocortisone, triamcinolone

Version: Abbreviated DOC List September 2010

Community Care of North Carolina (CCNC) & Physicians Advisory Group (PAG)

DRUGS OF CHOICE (DOC) LIST

More Details and Updated Versions May Be Downloaded at www.ncdoclist.com

N.C. Medicaid Preferred Drug List Criteria effective September 15, 2010
Drugs/Drug Classes with Clinical Criteria, Step Therapy, or Quantity Limits Step Therapy Quantity Limits Long-acting narcotic Epogen Amylin analogs Non-sedating analgesics antihistamine Lidoderm Angiotensin receptor combinations Second generation blockers and Myobloc anticonvulsants combinations Sedative Nuvigil hypnotics Opioid dependence Direct renin inhibitors Procrit Triptans Oral inhaled DPP-IV inhibitors and Provigil corticosteroids combinations Qualaquin Statins Growth hormones Synagis GLP-1 receptor agonists Approval for these classes can be obtained by writing meets PA criteria on the face of the prescription Justification for Use of Non-Preferred Medications Failed two preferred drugs (if only one preferred Clinical contraindication, co-morbidity, or unique patient drug is available, then failed one preferred drug) circumstance as a contraindication to preferred drug(s) Allergic reaction Age specific indications Drug-drug interaction Unique clinical indication supported by FDA approval or peer reviewed literature Previous episode of an unacceptable side effect or therapeutic failure Unacceptable clinical risk associated with therapeutic change Additional Resources 1. NC Medicaids full Preferred Drug List available at www.ncmedicaidpbm.com. Note: medications not addressed on the PDL may or may not be covered by NC Medicaid. Consult your network pharmacist for more information. 2. Prior Authorization request forms for medications that have clinical criteria for use are available at www.ncmedicaidpbm.com. 3. Non-preferred medications without clinical criteria may be accessed by submission of the North Carolina Medicaid Drug Request Form available at www.ncmedicaidpbm.com. 4. Prescribers can request access to a non-preferred medication or prior authorization by contacting ACS at 866246-8505 (telephone) or 866-246-8507 (fax). Clinical Criteria Leukotriene modifiers Topical antiinflammatories Aranesp Botox Celebrex Emend

For answers to questions about this reference guide, please contact your Network Pharmacist.

Version: Abbreviated DOC List September 2010