Medicaid-Approved Preferred Drug List (partial formulary entries)
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Lists formulary entries and coverage notes (OTC, PA, QL, DO, AL, SP) for Anthem Medicaid in North Carolina; affects prescribers, pharmacies, and prior authorization staff responsible for dispensing and reimbursement.
No material clinical or coverage changes in this revision.
Coverage summary & scope
This formulary excerpt is a legend-style listing of dermatologic and topical products with administrative coverage annotations. Items are presented with shorthand Notes such as QL (quantity limit), OTC (over-the-counter), and PA/SP for biologic injectables; no explicit clinical exclusion language or medical necessity criteria are provided in this segment. Examples include topical antifungals and corticosteroids (e.g., clotrimazole, clobetasol propionate) and specialty biologic entries (e.g., DUPIXENT — Notes = PA; SP), where the Notes indicate administrative controls rather than in-text coverage rules.
This portion of the legend lists miscellaneous oral products and macrolide antibiotics with Notes indicating administrative designations (for example, many tablet and suspension entries are shown without embedded clinical criteria). The extract shows OTC status applied to stool softeners and other items and does not include explicit exclusions or medical necessity statements for the listed medications.
The device and consumables segment enumerates lancets, lancing devices, control solutions, and CGM sensors/readers with Notes such as OTC, QL, and where applicable PA. This is a legend listing only — it does not provide medical necessity criteria or step-therapy sequences; it signals that quantity limits and prior authorization processes may apply to certain device items but defers to the payer's authorization processes for specific clinical rules.
This excerpt continues device and supply listings (meters, kits, alcohol swabs) annotated with administrative Notes (for example, meter kits annotated PA; OTC or lancets annotated OTC; QL). No explicit clinical exclusions are stated here — entries indicate which items are subject to quantity limits or prior authorization but do not contain the underlying coverage criteria.
The ophthalmic and selected injectable/specialty segment lists eye care products and multiple sclerosis/neurologic injectables with administrative flags. Ophthalmic agents include lubricants and antihistamines marked OTC or QL, and LASTACAFT is shown with PA; OTC; QL. Injectable specialty therapies (e.g., AVONEX, BETASERON) are annotated PA; SP; QL. These Notes reflect utilization management and specialty routing; explicit clinical coverage or exclusion rules are not provided in this extract.
This section lists acid-reducer and gastrointestinal products (including OTC-designated proton pump inhibitor formulations) with Notes indicating OTC status for many strengths. The entries are listing-level with administrative annotations (OTC, QL) rather than formal clinical coverage criteria or exclusion statements.
Formulary codes, NDCs and coding notes
| REPATHA | REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Notes = PA; QL |
| VANCIN | vancomycin hcl oral capsule - Notes = QL |
| ZYVOX | linezolid oral suspension/reconstituted and tablets - Notes = PA; QL |
| ELLENCE | ELLENCE INTRAVENOUS SOLUTION - Notes = PA; SP |
| MVASI | MVASI INTRAVENOUS SOLUTION - Notes = PA; SP |
| DUPIXENT | DUPIXENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR — Notes = PA; SP |
| DUPIXENT | DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE — Notes = PA; SP |
| PIMECROLIMUS | pimecrolimus external cream — Notes = PA; AL; QL |
| PODOFILOX | podofilox external solution — Notes = PA; QL |
| NORDITROPIN | NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN- INJECTOR — Notes = PA; SP; QL |
| SELARSDI | SELARSDI SUBCUTANEOUS SOLUTION (and IV) — Notes = PA; SP; QL |
| No codes listed |
Prior authorization, documentation and provider requirements
Prior authorization required
Products annotated with 'PA' require prior authorization before claim payment. Claims for items marked PA may be denied if a prior authorization is not obtained and documented.
- Trigger: any product line with Notes = PA
- Examples: REPATHA, DUPIXENT, SELARSDI, AVONEX, DEXCOM sensors, OMNIPOD kits, AIMOVIG, EMGALITY, various oncology and specialty injectables
Prior authorization and specialty routing indicated
PA and SP together indicate the product requires prior authorization and specialty routing (distribution through specialty pharmacy or site-of-care controls). For SP items, expect specialty handling and documentation requirements during the authorization process.
- Trigger: Notes include both PA and SP
- Examples: MVASI, DUPIXENT, ARANESP, ENSPRYNG, AVONEX, REBIF
Legend — coverage note meanings
Legend shorthand (PA, QL, AL, DO, SP, OTC) conveys coverage controls. Use the legend to interpret whether prior authorization, quantity limits, age limits, dispensing or specialty routing apply.
- PA = Prior Authorization required
- QL = Quantity Limit
- AL = Age Limit
- DO = Dispense as directed / dispensing program indicator
- SP = Specialty product routing
- OTC = Over-the-counter status
Quantity limit and step/dispensing indicators
Quantity limits (QL) and step/alternative-therapy indicators (AL, DO) are present across the listing. QL flags may require clinical justification for override; AL flags restrict based on member age. DO may indicate dispensing program or site-of-care requirements.
- QL may limit allowed quantity per fill or time period
- AL enforces age-based limits (e.g., pediatric vs adult formulations)
- DO indicates dispensing or site-of-care/dispensing program constraints
Documentation expectations for PA/SP/QL items
Documentation supporting PA/SP/QL requests is expected. Include clinical rationale, prior therapies tried (when applicable), dosing, and member-specific information to facilitate approval. Specialty products often require additional ordering/provider certifications and specialty pharmacy routing details.
- Attach relevant medical records and prior therapy history
- For SP items, include preferred specialty pharmacy and shipping/site-of-care details
- Be prepared to submit age verification for AL items and dosing calculations for QL overrides
Injectable biologics and on-body injectors
Injectable biologics, on-body injectors and device-related products are frequently flagged PA; SP; QL. Examples include on-body injectors and biologic prefills — these require prior authorization and may have specialty distribution or quantity controls.
- On-body injectors: UDENYCA examples (PA; SP; QL)
- Injectable biologics: ARANESP, HAEGARDA, TAKHZYRO (PA; SP; QL)
Prior authorization required for selected injectables and specialty antivirals
Selected injectables, specialty antivirals, and other high-cost agents require prior authorization. Examples from the list include oncology biologics, selected antivirals and long‑acting injectables.
- Oncology/specialty: MVASI (PA; SP), mitoxantrone (SP)
- Antivirals/specialty antivirals: select antiviral group entries showing SP/PA indicators
- Long‑acting injectables: RISPERDAL CONSTA, INVEGA SUSTENNA (PA; AL; QL)
Prior authorization required for select CGM and device items
Continuous glucose monitoring (CGM) devices, sensors and associated transmitters are flagged PA and QL in the formulary. Prior authorization is required for CGM receivers, sensors and transmitters; coverage may be subject to quantity limits and clinical criteria.
- Dexcom G6/G7 receivers, sensors, transmitters — Notes = PA; QL
- FreeStyle Libre sensors/readers — Notes = PA; QL
- Omnipod kits and pods — Notes = PA; QL
Denial triggers linked to Notes flags
Claims for items annotated with PA/QL/AL without an approved authorization or supporting documentation are at risk of denial. Ensure the appropriate PA number and documentation are submitted with the claim or prior to dispensing to avoid denial.
- Denial triggers: missing PA number, exceeded QL, age mismatch for AL items
- Operational note: verify PA before dispensing and document in chart
Step therapy and alternative-therapy flags — provider action
When a product listing includes step therapy or alternative-therapy flags (AL, DO, QL), no explicit step sequence may be shown in this section. Providers should consult the payer's clinical policy or prior authorization portal for step edits and required trialed therapies.
- Step therapy sequences are not included here — check clinical policies
- Examples: dermatologic immunomodulators (PA; AL; QL) show flags but no sequence in this listing
Legend & abbreviations
Step therapy signals and presence
| Coverage note | Implication |
|---|---|
| SP or PA noted on oncology/specialty agents (e.g., MVASI, mitoxantrone, vinorelbine) | |
| May imply specialty distribution or prior authorization controls; explicit step-therapy sequences are not provided in this listing |
| Coverage note | Implication |
|---|---|
| DO and AL annotations present on multiple oral and long-acting formulations (examples: clozapine entries, haloperidol, lithium products) | |
| DO (dispense/dispensing designation) and AL (age or additional limitation) suggest dispensing/program restrictions or age-based limits; no explicit step sequence is specified |
| Coverage note | Examples | Implication |
|---|---|---|
| PA; SP; QL | ||
| ambrisentan; sildenafil; tadalafil (PA; SP; QL noted) | ||
| Products marked PA (and often SP) require prior authorization and may be routed via specialty channels; step edits are not detailed in this excerpt |
| Coverage note | Implication |
|---|---|
| PA; AL; QL noted for some topical and dermatologic agents (e.g., pimecrolimus, podofilox) | |
| Annotation suggests prior authorization or requirement to try alternative/step therapies prior to coverage, though specific step requirements are not provided here |
| Coverage note | Implication |
|---|---|
| Multiple entries show PA, QL, or SP flags but no ordered step sequences (examples: various gout and hematologic agents) | |
| PA/QL/SP flags indicate utilization management (authorization, quantity limits, specialty routing) without explicit step-therapy sequences in this fragment |
| Coverage note | Examples | Implication |
|---|---|---|
| PA; QL | ||
| Omnipod kits/pods (OMNIPOD 5 kits/pods) — Notes = PA; QL | ||
| Device listings labeled PA and QL indicate prior authorization and quantity limits will apply before coverage; step sequencing is not specified |
| Coverage note | Examples | Implication |
|---|---|---|
| PA; QL | ||
| AIMOVIG, EMGALITY and other migraine products annotated PA; QL | ||
| Prior authorization and quantity limits may be required for coverage of some migraine acute and preventive therapies; explicit step rules are not included here |
| Coverage note | Implication |
|---|---|
| Many entries annotated with OTC, QL, or PA (e.g., acid reducer OTC listings) | |
| This excerpt contains no explicit step-therapy sequences; annotations indicate OTC status, quantity limits, or prior authorization where noted |
| Coverage note | Examples | Implication |
|---|---|---|
| PA; SP; QL | ||
| AVONEX, BETASERON, dimethyl fumarate, glatiramer, REBIF, TERIFLUNOMIDE noted PA; SP; QL | ||
| Specialty agents flagged PA/SP/QL are subject to prior authorization, specialty pharmacy routing, and quantity limits; specific step or channel workflows are not detailed in this fragment |
| Coverage note | Observation |
|---|---|
| Listings are at the product level with Notes flags (PA, QL, SP, DO, AL) | |
| Entries are listing-level annotations; no explicit step therapy sequences appear in the provided segments |
Quantity limit flags and affected items
Specialty channel, infusion and site restrictions
SP may imply infusion center/site‑of‑care management
Specialty products may be managed through infusion centers or specialty distribution channels; the legend’s SP flag indicates specialty handling though site‑specific rules are not detailed here.
SP items require specialty pharmacy management
Products annotated SP are handled via specialty pharmacy channels and require the appropriate specialty routing and documentation.
Route SP products through specialty pharmacy
When an item is marked SP in the legend, route the prescription through the specialty pharmacy channel and provide specialty documentation as required by the payer.
Policy background & scope
Background: this fragment is a partial Preferred Drug List (PDL) legend that enumerates pharmaceuticals and devices for Anthem Medicaid (North Carolina) with shorthand Notes used to indicate coverage controls. The listing format emphasizes administrative flags — for example, PA (prior authorization), QL (quantity limit), OTC (over-the-counter), SP (specialty) — and does not include the full medical necessity criteria or step-therapy sequences for the named products. Providers and pharmacy staff should follow the payer's PA and QL processes where those Notes appear to ensure proper adjudication.
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