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2010 Prescription Drug List
This formulary reference guide lists medications by drug class and by tier level of Generic, Preferred Brand, and Non-Preferred Brand.
This is not a complete listing of the medications covered by FirstCarolinaCare Insurance Company (FCC) nor does it guarantee coverage. Changes to the formulary can occur any time during the plan year. A complete listing of medications and coverage information can be found at www.medimpact.com by clicking on “member” and signing in on the password protected site. Once signed in, you can obtain current information specific to your pharmacy benefits.
| Generics* | Preferred Brands* | Non-Preferred Brands* |
| Allergy Antihistamines | ||
| fexofenadine hydroxyzine OTC Claritin/D OTC Zyrtec/D |
Astelin Nasal Spray Astepro Nasal Spray |
Allegra D/ODT/ Susp Clarinex/D Patanase Nasal Spray Xyzal Zyrtec/D (RX only) |
| Allergy-Nasal Corticosteroids | ||
| flunisolide fluticasone (Flonase) |
Nasacort AQ Nasonex Rhinocort AQ |
Beconase AQ Omnaris Veramyst |
| Anaphylaxis | ||
| epinephrine | Adrenaclick Epipen/JR Twinject |
|
| Antibiotics | ||
| amoxicillin amoxicillin/clavulanate ampicillin azithromycin cefaclor/ER cefradroxil cefdinir cefpodoxime cefprozil cefuroxime cephalexin ciprofloxacin/ER clarithromycin/ER clindamycin dicloxacillin doxycycline (tabs/caps) erythromycin/sulfasoxzole metronidazole minocycline nitrofurantoin/macro ofloxaxin penicillin VK SMP/TMP tetracycline |
Augmentin XR Avelox Ceftin suspension Cipro suspension Levaquin Vancocin (QL) Zyvox (QL) |
Cedax Cleocin syrup Doryx Eryped Ery-tab E.E.S. Factive Flagyl ER Gantrisin Keflex 750mg caps Ketek (ST) Maxaquin Moxatag Noroxin Oracea Proquin XR Solodyn (PA) Spectracef Suprax Zmax |
| Antidepressants | ||
| amitriptyline bupropion/ SR/XL citalopram clomipramine doxepin fluoxetine fluvoxamine imipramine maprotiline mirtazepine/soltab nefazodone nortriptyline paroxetine/CR protriptyline selferma capsule sertraline (Zoloft) trazodone |
Cymbalta Effexor XR Marplan Nardil Venlafaxine ER tablets (QL) |
Aplenzin (PA) Lexapro (TS) Luvox CR Pexeva (PA) Pristiq Prozac Weekly (PA) Sarafem tablets (PA) |
| Generic* | Preferred Brand* | Non-Preferred Brand* |
| tranylcypromine venlafaxine IR tablets |
||
| Antiemesis/Antivertigo | ||
| granisetron (MD, QL) ondansetron/ODT (QL) promethazine |
Emend (MD, QL) | Anzemet (MD, QL) Sancuso (MD, QL) |
| Anti-Incontinence/Urinary Tract Antispasmodics | ||
| flavoxate oxybutynin/ER |
Oxytrol Detrol/LA Vesicare |
Sanctura/XR Enablex Gelnique Toviaz |
| Antilipemic (Cholesterol Lowering Agents) | ||
| cholestyramine colestipol fenofibrate/fenofibric acid gemfibrozil lovastatin pravastatin (TS) simvastatin (TS) |
Advicor Lipitor (TS) Lipofen Niaspan Simcor Tricor Vytorin Welchol Zetia |
Altoprev Antara Caduet Crestor (TS) Fenoglide Lescol/XL Lovaza Triglide Trilipex |
| Anti-Migraine | ||
| butalbital/APAP or ASA/ caffeine butorphanal nasal (QL) divalproex ER ergotamine/caffeine isometheptene/APAP/caffeine sumatriptan (Imitrex) (QL) topiramate |
Maxalt/ MLT (QL) Relpax (QL) Zomig/ ZMT (QL) |
Amerge (QL) Axert (QL) Frova (QL) Migranal (QL) Prodrin Treximet (QL) |
| Anti-Parkinson Agents | ||
| amantadine carbidopa-levodopa pramipexole ropinirole selegiline |
Azilect Comptan Requip XL Stalevo Tasmar Zelapar |
|
| Anti-Ulcer/Gastrointestinal (Heartburn, Reflux Relief) | ||
| cimetidine famotidine lansoprazole caps (ST, QL) nizatidine omeprazole (QL) pantoprazole (ST, QL) Prilosec OTC (QL) ranitidine sucralfate |
Aciphex (ST, QL) Helidac Dexilant (ST, QL) Nexium (ST, QL) Prevacid Solutab (ST, QL) Prevpac Zegerid (ST, QL) |
|
| Anti-viral | ||
| acyclovir famciclovir |
Tamiflu (QL) Valtrex Crixivan |
Relenza (QL) Valcyte |
| Asthma/COPD | ||
| albuterol neb albuterol/ipratropium neb cromolyn neb ipratropium neb metaproterenol terbutaline theophylline |
Advair Diskus/HFA Asmanex Atrovent HFA Combivent Flovent Diskus/HFA Foradil Perforomist Proair HFA Proventil HFA Pulmicort/Respules QVAR Serevent Diskus Singulair (ST) Spiriva Ventolin HFA Xopenex neb (ST) |
Aerobid/M Accolate (ST) Alvesco Azmacort Brovana Maxair Symbicort Theo-24 Xolair (PA) Xopenex HFA (ST) Zyflo/CR (ST) |
| Generic* | Preferred Brand* | Non-Preferred Brand* |
| Attention Deficit Hyperactivity Disorder (ADHD/ADD) | ||
| dexmethylphenidate IR (QL) dextroamphetamine IR/SA dextroamphetamine/amphetamine salts IR (QL)/ SR (Age, QL) methylphenidate IR/SA |
Metadate CD (Age, QL) Strattera (Age, QL) |
Concerta (Age, QL) Daytrana (Age, QL) Focalin XR (Age, QL) Intuniv (Age, QL) Ritalin LA (Age, QL) Methylin (Age, QL) Vyvanse (Age, QL) |
| Atypical Antipsychotics | ||
| clozapine risperidone |
Abilify (ST) Geodon Risperdal Consta Seroquel/XR Zyprexa/ zydis |
Fanapt Fazaclo Invega (QL) Saphris Symbyax |
| Benign Prostatic Hypertrophy (BPH) | ||
| doxazosin finasteride prazosin terazosin |
Avodart Flomax |
Uroxatral Cardura XL Rapaflo |
| Cardiovascular-ACE Inhibitors/ARBS/Renin/Combinations | ||
| benazepril/HCTZ captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ lisinopril/HCTZ moexipril/HCTZ perindopril quinapril/HCTZ ramipril (Altace capsules) trandolapril |
Atacand/HCT (ST) Azor (ST) Benicar (ST, TS) Cozaar (ST) Diovan/HCT (ST) Exforge/HCT (ST) Hyzaar (ST) Micardis/HCT (ST) Tekturna/HCT |
Avalide (ST) Avapro (ST) Teveten/HCT (ST) Twynsta (ST) |
| Cardiovascular-Alpha/Beta Blockers/Combinations | ||
| acebutolol atenolol/chlorthalidone betaxolol bisoprolol/HCTZ carvediolol labetalol metoprolol/HCTZ metoprolol ER nadolol pindolol propranolol/HCTZ sotalol timolol |
Bystolic Coreg CR Innopran XL Levatol |
|
| Cardiovascular- Calcium Channel Blockers/Combinations | ||
| amlodipine/benazepril diltiazem/CD/CR/SR felodipine isradipine nicardipine nifedipine/SA/ER nimodipine verapamil/LA/PM/SR |
Azor (ST) Cardizem LA Exforge/HCT (ST) Lotrel Sular |
Caduet Cardene SR Cardizem CD 360mg Covera HS Dynacirc CR Tarka Twynsta (ST) |
| Cardiovascular-Diuretics | ||
| amiloride/HCTZ bumetanide chlorothiazide chlorthalidone eplerenone (ST, QL) furosemide HCTZ indapamide metolazone spironolactone/HCTZ torsemide triamterene/HCTZ |
Diuril oral susp Dyrenium |
|
| Generic* | Preferred Brand* | Non-Preferred Brand* |
| Cardiovascular-Vasodilators | ||
| isosorbide mono/di-nitrate nitroglycerin |
Nitrolingual NS | Dilatrate SR Nitro-Bid Nitrostat |
| Contraceptives | ||
| apri aranelle balziva/zenchent camila cryselle enpresse errin junel/fe kariva lessina low-ogestrel lutera medroxyprogesterone (QL) microgestin/FE mononessa/FE necon nordette nortrel ocella sprintec tri-levlen tilia fe/tri-legest fe tri-sprintec/tri-lo trinessa trivora zovia |
Nuvaring Lybrel Ortho Evra Seasonique (QL) Yaz |
Femcon FE Lo Seasonique Loestrin 24 FE Ovcon-50 |
| Dermatology | ||
| calcipotriene solution claravis (PA) sotret (PA) |
Benzaclin Condylox gel Dovonex cream Duac CS Elidel Protopic Tazorac |
Azelex Aczone |
| Diabetes | ||
| acarbose chlorpropamide glimepiride glipizide/ ER glipizide/metformin glyburide glyburide/metformin metformin/ER nateglinide tolazamide tolbutamide |
Actos Actoplus Met Avandamet Avandaryl Avandia Duetact Humulin/Humalog Januvia/Janumet Lantus Levemir Novolin/Novolog Prandin |
Apidra Byetta Fortamet Glumetza Diabeta Glyset Onglyza Prandimet Riomet Symlin Victoza |
| Diabetes-Diagnostics | ||
| Accu-Chek Ascensia Breeze Contour Freestyle One-Touch Precision Prestige Softclix Soft Touch True Track |
||
| Ear-General | ||
| neomycin/polymixin/HC | Ciprodex | Cipro HC |
| Generic* | Preferred Brand* | Non-Preferred Brand* |
| Erectile Dysfunction | ||
| yohimbine (G) | Caverject (G, QL) Edex (G, QL) Viagra (G, QL) |
Cialis (G, QL) Levitra (G, QL) |
| Eye-General | ||
| gentamicin tobramycin |
Alrex Iquix Lotemax Patanol Pataday Optivar Restasis (QL) Tobradex Vigamox Zymar |
Acular/LS Emadine FML/forte Quixin Tobrex Zylet |
| Eye-Glaucoma | ||
| betaxolol brimonidine dorzolamide levobunolol metipranolol pilocarpine timolol/XE timolol/dorzolamide |
Alphagan P Betiptic S Lumigan Travatan/Z Xalatan |
Azopt Betimol Istalol Combigan Pilopine HS |
| Gastrointestinal Disorders-General | ||
| balsalzide mesalamine |
Asacol Canasa Creon Ultrase/MT Viokase |
Asacol HD Zenpep |
| Hormone Replacement | ||
| estradiol estradiol patches estropipate medroxyprogesterone syntest hs/ds |
Activella Alora Combipatch Estraderm Estring (QL) Femring (QL) Premarin Premphase Prempro Prometrium Testim Vagifem Vivelle-Dot |
Angeliq Cenestin Climara Pro Divigel Elestrin Enjuvia Estrace Cream Estrasorb Estrogel Evamist FemHRT Femtrace Menest Menostar Prefest |
| Immunomodulators | ||
| Aldara | Alferon N (PA) Actimunne (PA) Intron A (PA) |
|
| Multiple Sclerosis | ||
| Avonex (PA) Betaseron (PA) Copaxone (PA) Rebif (PA) |
||
| Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) | ||
| diclofenac etodolac ibuprofen indomethacin ketoprofen ketorolac (QL) meloxicam nabumetone naproxen |
Celebrex (Age, ST) | Arthrotec Flector patch Naprelan Ponstel Prevacid Naprapac (QL) Voltaren Gel Zipsor |
| Generic* | Preferred Brand* | Non-Preferred Brand* |
| oxaprozin piroxicam salsalate sulindac |
||
| Osteoporosis | ||
| alendronate calcitonin spray |
Actonel Actonel with Calcium Evista Fortical Fosamax +D |
Boniva Forteo (PA) |
| Narcotics-Pain | ||
| acetaminophen w/ codeine fentanyl patch (ST, QL) morphine sulfate methadone oxycodone/APAP or ASA |
Avinza (PA) Oxycontin (PA) |
Dilaudid Fentora (QL) Nucynta (ST) Opana/ER (ST) |
| Platelet Aggregation Inhibitors/Anticoagulants | ||
| cilostazol dipyridamole ticlopidine warfarin |
Aggrenox Coumadin Lovenox (QL) Plavix |
Arixtra (QL) Effient Fragmin (QL) Innohep (QL) |
| Sedatives/Hypnotics (Sleep Aids) | ||
| diazepam estazolam flurazepam lorazepam oxazepam temazepam triazolam zaleplon zolpidem |
Ambien CR (PA) Doral Edluar (PA) Lunesta (PA) Rozerem (PA) |
|
| Seizure Disorder-Anticonvulsants | ||
| carbamazepine/XR divalproex DR/ER/sprinkle gabapentin lamotrigine (TS) levetiracetam oxcarbazepine tablets (ST) phenytoin topiramate valproate valproic acid zonisamide |
Carbatrol Diastat Dilantin Phenytek Tegretol XR |
Banzel Felbatol Gabitril Keppra XR Lamictal ODT/XR (PA) Lyrica Sabril Stavzor Trileptal Susp (ST) Vimpat |
FCC uses certain tools to help promote the use of safe and cost-effective medications and to reduce the potential for abuse or misuse of medications.
These restrictions include:
| *AGE | Age Edit: | Coverage may depend on patient age |
| *G | Gender Edit: | Coverage may depend on patient gender |
| *PA | Prior Authorization: | Requires specific provider request process |
| *QL | Quantity Limit: | Coverage may be limited to specific quantities per prescription and/or time period |
| *MD | Physician Specialty: | Coverage may depend on prescribing physician's specialty or board certification |
| *ST | Step Therapy: | Coverage may depend on previous use of another drug |
| *TS | Tablet Splitting: | Medication may be eligible for Tablet Splitting Program, "Split the Pill, Split Your Bill" |