CurrentCareSourcePolicy N/A

Preferred Drug List (PDL) — Analgesics and NSAIDs

Lists preferred and non-preferred prescription drugs within analgesic and nonsteroidal antiinflammatory agent classes for CareSource members in North Carolina; explains override process for prescribers and notes effective implementation dates for edits at point-of-sale.

Policy Summary

PayerCareSource

PolicyPreferred Drug List (PDL) — Analgesics and NSAIDs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionIf a prescribed drug is non-preferred, prescribers must call the Prime Therapeutics State Government Solutions Help Desk (1-800-424-7895) and choose the PDL option to request an override.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4/1/2026PDL effective

no PAMAT injectables

preferred/non-preferredStatus per drug

NCGeography

Coverage Criteria and Formulary Designations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary status rules

Covered as preferred when listed as PREFERRED; non-preferred drugs may require override or prior authorization.

Preferred drugs: Drugs explicitly listed under 'PREFERRED' in each class are the formulary-preferred agents for point-of-sale processing.

See drug lists per class (examples in cited chunks).

Non-preferred drugs: Drugs listed under 'NON-PREFERRED' or 'INCLUDE BUT NOT LIMITED TO' within non-preferred sections are non-preferred; prescribers may request an override via the Prime Therapeutics State Government Solutions Help Desk and some non-preferred agents may require prior authorization or manual review.

New products in a reviewed drug class are considered non-preferred until committee review.

Formulary preference listings

Formulary status entries in this excerpt list drugs as Preferred, Non-Preferred, or Non-Preferred with Criteria within specific drug classes.

HIV Agents - Preferred: Preferred HIV agents are those listed under 'PREFERRED' (examples include PREZISTA suspension/tablet, REYATAZ, RITONAVIR tablet (generic for NORVIR), STRIBILD, SYMFI, SYMTUZA (brand only), TENOFOVIR DISOPROXIL FUMARATE (generic for VIREAD), TRIUMEQ, TIVICAY, TYBOST, ZIDOVUDINE tablet and syrup).

Original posted preferred status: 10/1/2023.

HIV Agents - Non-Preferred: Enumerated non-preferred HIV agents include many products listed under 'NON-PREFERRED - INCLUDE BUT NOT LIMITED TO' (examples: APTIVUS, EDURANT pediatric suspension, various generics and branded agents).

See HIV sections across cited chunks for full lists.

HIV Agents - Non-Preferred with Criteria: Select HIV agents are listed 'NON-PREFERRED - WITH CRITERIA' (examples: APRETUDE, CABENUVA, MARAVIROC/SELZENTRY, SUNLENCA, YEZTUGO) with an effective date noted (4/1/2026) and may require criteria or prior authorization.

May require prior authorization or criteria review.

Tetracycline Agents - Preferred: Preferred tetracycline agents include multiple doxycycline and minocycline formulations (listed under 'PREFERRED' in the tetracycline section).

Original posted preferred status: 1/1/2026.

Targeted Immune Modulators - Preferred: Preferred targeted immune modulators include agents such as ENBREL, HUMIRA, OTEZLA, TALTZ, XELJANZ, and select brand presentations as listed under 'PREFERRED'.

Updated in cited chunks (dates shown).

Targeted Immune Modulators - Non-Preferred: Numerous biologic agents and biosimilars are listed under 'NON-PREFERRED - INCLUDE BUT NOT LIMITED TO'; some entries are marked brand-only or have additional notes.

Refer to PDL Criteria Overview where indicated.

Multiple Sclerosis Agents - Preferred: Preferred MS agents include DUPIXENT, GAMMAGARD, AMPYRA ER, FASENRA, GAMUNEX-C, AVONEX, XOLAIR, HIZENTRA, and COPAXONE 20MG (brand only) as listed under 'PREFERRED'.

Multiple update dates noted in the PDL.

Formulary status rules

Drugs are categorized as Preferred or Non-Preferred within each therapeutic class; new products default to Non-Preferred until committee review.

Preferred: Specific drugs listed under 'PREFERRED' headings in each class are the formulary-preferred agents and are intended to be favored in point-of-sale processing.

See PREFERRED headings in cited chunks for examples (e.g., chunk 149).

Non-Preferred: Drugs listed under 'NON-PREFERRED' or 'NON-PREFERRED - INCLUDE BUT NOT LIMITED TO' are considered non-preferred and may require an override or prior authorization for coverage.

Examples and full lists appear in cited chunks (e.g., chunks 144, 150, 156).

New products in a reviewed drug class are considered non-preferred until the committee has reevaluated the evidence for the drug class.

Document notes this policy for new products (see chunk 147/related notes).

Formulary designation by drug class

Agents are designated Preferred or Non‑Preferred within each CNS drug class; some branded agents require manual review.

Anticonvulsants: Preferred and non-preferred anticonvulsant agents are listed separately; many generics appear in the non-preferred 'include but not limited to' lists and prescribers should reference the PDL for specific products.

See anticonvulsant lists in cited chunks.

Antidepressants (SSRIs/SNRIs): Preferred SSRIs/SNRIs are listed under 'PREFERRED' (examples in chunk 166); non-preferred agents and items referencing the PDL Criteria Overview are listed separately; some agents may be marked 'MANUAL REVIEW.'

Refer to cited chunks for full preferred and non-preferred lists.

Anti-Parkinson's agents: Preferred anti‑Parkinson's agents are listed under 'PREFERRED' headings (examples include amantadine, benztropine, carbidopa/levodopa); non‑preferred agents appear in include-but-not-limited sections.

See chunk 171.

ADHD agents: Preferred ADHD agents (e.g., ADDERALL XR, methylphenidate ER products, atomoxetine) are listed under 'PREFERRED'; non-preferred agents are listed in adjacent columns and some formulations are brand-only preferred.

See chunk 177 for preferred ADHD listings.

Preferred Class 5 (Lower-Mid)

Preferred — Class 5 (Lower-Mid Strength)

Preferred Class 5 agents: Betamethasone valerate 0.1% cream (15 gm, 45 gm); Fluocinolone 0.01% cream (15 gm, 60 gm); Fluocinolone 0.025% cream (15 gm, 60 gm); Fluticasone propionate 0.05% cream (15 gm, 30 gm, 60 gm); Triamcinolone 0.025% lotion/ointment (60 ml, 15 gm, 80 gm); Triamcinolone 0.1% lotion (60 ml).

Sizes included as listed in the PDL.

Preferred with Criteria — Manual Review

Preferred with criteria (manual review)

Preferred with manual review: Agents listed under 'PREFERRED WITH CRITERIA (MANUAL REVIEW)' require manual review prior to coverage (examples include hydrocortisone-pramoxine 1%-1% cream; hydrocortisone 0.5% cream (covered OTC) in listed sizes; ADBRY (tralokinumab-ldrm); DUPIXENT (dupilumab); certain hemorrhoidal topical products listed).

Manual review required for coverage as indicated in the PDL.

Other Listed Agents

Included but not limited to (other agents listed)

Additional listed dermatology agents: Other agents listed in the dermatology sections include EBGLYSS (lebrikizumab-lbkz), CORTIFOAM, EUCRISA (crisaborole), NEMLUVIO (nemolizumab-ilto), OPZELURA (ruxolitinib), PIMECROLIMUS, PROTOPIC (tacrolimus), RINVOQ (upadacitinib), VTAMA (tapinarof), ZORYVE (roflumilast), and others shown.

Some entries are marked with * indicating specialty biologics; effective dates noted in the PDL.

Coverage by formulary designation

Drug coverage status as listed — claims adjudicated according to preferred/non-preferred designation and effective implementation dates.

Preferred products: Products explicitly listed under 'PREFERRED' for each class are the formulary-preferred agents and expected to be covered at point-of-sale (examples: metformin formulations, selected SGLT2 agents and sulfonylureas listed as preferred where indicated).

Point-of-sale edits apply per effective implementation dates shown in the PDL.

Non-preferred products: Products listed as 'NON-PREFERRED' or 'NON-PREFERRED - INCLUDE BUT NOT LIMITED TO' are considered non-preferred and may require an override or prior authorization; new products default to non-preferred until committee review.

Examples include specific topical agents and antidiabetic agents noted in cited chunks.

Included but not limited to: 'Include but not limited to' sections list additional products in a class that may be non-preferred or otherwise designated; inclusion in these lists is illustrative and not exhaustive.

Refer to the PDL Criteria Overview for class-specific adjudication and any criteria that apply.

This Preferred Drug List (PDL) groups medications by therapeutic class and indicates formulary placement at the drug-class and product level. Drugs explicitly listed under PREFERRED headings are the formulary-preferred agents for point-of-sale processing. Drugs listed as NON-PREFERRED or under INCLUDE BUT NOT LIMITED TO / NON-PREFERRED are considered non-preferred and may require an override or prior authorization. New products placed into a previously reviewed class are treated as NON-PREFERRED until the PDL committee re-evaluates the evidence; the document’s effective implementation dates indicate when point-of-sale edits will apply.

The document enumerates multiple examples of non-preferred agents across classes. Examples include NSAIDs and related formulations (e.g., NAPROXEN SUSPENSION, ORUDIS (KETOPROFEN), OXAPROZIN) and non-preferred triptans and migraine products (e.g., AMLOTRIPTAN, ELETRIPTAN, FROVA, ZOMIG). Preventive migraine biologics such as AJOVY and certain strengths of EMGALITY are also listed as non-preferred. Additional non-preferred listings include butalbital combinations and topical agents (e.g., BUTALBITAL-APAP, MUPIROCIN) and multiple antiretroviral agents shown under non-preferred HIV listings.

Procedure and Billing Codes

No procedure or billing codes listed in these chunksmixed

No codes listed

Covered/Naming entriesmixed

N/A	No procedure or billing codes listed in this segment

Drug listings (no procedure/diagnosis codes in this segment)mixed

No codes listed

inv-25: N/A — coding key/value placeholder

CodingN/A

NotesNo procedure or billing codes listed in this document segment

ReferencePreferred Drug List document (effective 4/1/2026)

inv-26: Empty/placeholder coding key/value

CodingEmpty/placeholder

ActionNo codes provided in the PDL excerpt; refer to payer coding tables if required

SourcePreferred Drug List provider document

Provider Actions, Overrides, and Prior Authorization

Prior Authorization

Override / Prior Authorization Process

Prescribers may request an override for non‑preferred drugs or initiate a prior authorization request by calling the Prime Therapeutics State Government Solutions Help Desk (Toll Free: 1-800-424-7895) and choosing the PDL option. Claims for non‑preferred products may be edited or denied at point‑of‑sale unless an override or prior authorization is obtained. New products within a reviewed drug class are considered NON‑PREFERRED until the Committee reevaluates the class; the effective implementation date for each drug class is the date point‑of‑sale edits will apply. For the most up‑to‑date Preferred Drug List and PDL Criteria Overview (for step edits and prior authorization details) visit https://ar.primetherapeutics.com/provider-documents.

Override/Prior Authorization: Call Prime Therapeutics State Government Solutions Help Desk — Toll Free 1-800-424-7895 and choose the PDL option.
Point-of-Sale Edits: Claims may be edited or denied at point-of-sale for non-preferred drugs; obtain override/PA to avoid denial.
New Product Status: New products default to NON‑PREFERRED until Committee review; effective dates drive point-of-sale edits.
PDL Criteria Overview: Refer to the PDL Criteria Overview for step therapy and prior authorization details (some agents reference manual review).

Billing Rule

MAT Injectables — Billing and PA Guidance

Certain medications may be billed either through the pharmacy benefit or the medical benefit. For medication‑assisted treatment (MAT) injectables listed as preferred, no prior authorization is required when billed through pharmacy. BRIXADI (buprenorphine) SQ syringe, SUBLOCADE (buprenorphine) SQ injection, and VIVITROL (naltrexone) IM are listed as preferred MAT injectables with no PA required. Providers may bill these agents through pharmacy or medical benefits as appropriate.

Preferred MAT injectables (no PA required when billed via pharmacy): BRIXADI SQ syringe (buprenorphine); SUBLOCADE SQ injection (buprenorphine); VIVITROL IM (naltrexone).
Billing: May be billed through pharmacy or medical benefits — follow payer billing guidance for the chosen benefit.

Documentation Required

Preferred with Criteria / Manual Review Required

Some agents are designated as Preferred (brand‑only) or Preferred with Criteria (Manual Review). Preferred with Criteria items require a manual review / prior authorization pathway and supporting clinical documentation to demonstrate that coverage criteria are met. Examples include dermatologic biologics and other specialty products listed as "Preferred with Criteria (Manual Review)"; see the PDL Criteria Overview for the required documentation.

Preferred with Criteria (Manual Review): entries such as ADDBRY/DUPIXENT and selected hydrocortisone formulations require manual review.
Documentation: Providers should supply clinical justification and supporting records when requesting manual review or prior authorization.
Reference: See the PDL Criteria Overview for specific clinical criteria and step requirements.

Denial Risk

Non‑Preferred Drugs — Overrides and Point‑of‑Sale Edits

Non‑preferred agents may be subject to additional coverage rules including prior authorization, point‑of‑sale denials, or manual review. Examples of non‑preferred agents that may require prior authorization or manual review are listed on the PDL (e.g., certain injectables, specialty agents, and new products). When a drug is listed as non‑preferred, prescribers should contact the Prime Therapeutics help desk to request an override or submit necessary prior authorization documentation to avoid claim denial.

Non‑Preferred with Criteria: e.g., APRETUDE, CABENUVA, SELZENTRY (maraviroc), LENACAPAVIR products — may require prior authorization or manual review.
Non‑Preferred Lists: Many biologics and specialty agents are listed as non‑preferred; refer to the PDL for specifics.
Override Process: Contact Prime Therapeutics Help Desk to request an override or to begin the PA process.

Documentation Required

Override and Documentation Process

Providers should document override requests and prior authorization decisions in the patient record. When contacting the Prime Therapeutics Help Desk, choose the PDL option and be prepared to provide clinical rationale, pertinent medical records, previous therapy history, and any other items specified in the PDL Criteria Overview. Retain documentation of approvals or denials to support billing and any potential appeals.

Documentation required for override/PA: clinical rationale, treatment history, relevant medical records.
Help Desk Workflow: Call 1-800-424-7895, choose PDL option; follow instructions for submitting documentation.
Recordkeeping: Keep copies of authorizations or override confirmations for billing and appeals.

Definitions and Key Terms

inv-88: Preferred — drugs designated as preferred on the PDL.

DefinitionDrugs listed under 'PREFERRED' headings on the PDL are formulary-preferred agents for coverage and point-of-sale processing.

ImplicationPreferred status favors coverage at point-of-sale per the effective implementation date.

MaintenancePDL is subject to change; refer to Prime Therapeutics provider documents for updates.

inv-89: Non-Preferred — drugs designated non-preferred; overrides available via Prime Therapeutics help desk; new products default non-preferred.

DefinitionDrugs listed as 'NON-PREFERRED' or under 'INCLUDE BUT NOT LIMITED TO' are non-preferred and may require an override or prior authorization.

Override ProcessPrescribers may request an override by calling the Prime Therapeutics State Government Solutions Help Desk (Toll Free 1-800-424-7895) and choosing the PDL option.

New ProductsNew products in a reviewed drug class default to NON-PREFERRED until committee review.

inv-90: MAT injectables — BRIXADI, SUBLOCADE, VIVITROL identified as preferred MAT injectables that do not require prior authorization.

DrugsBRIXADI SQ (buprenorphine), SUBLOCADE SQ (buprenorphine), VIVITROL IM (naltrexone)

PA RequirementNo prior authorization required when billed through the pharmacy (PDL: 'NO PA REQUIRED (PHARMACY)')

BillingMay be billed through pharmacy or medical benefits per PDL note

inv-91: Preferred Drug List (PDL) — formulary listing maintained by the payer identifying preferred and non-preferred drugs.

DefinitionPreferred Drug List (PDL) — a formulary maintained by the payer that designates drugs as preferred or non-preferred for claims editing and prescribing guidance.

PurposeUsed to adjudicate claims at point-of-sale based on status and effective implementation dates.

UpdatesPDL is subject to change; the most current list is available at the Prime Therapeutics provider documents URL.

inv-92: PDL abbreviation definition.

AbbreviationPDL = Preferred Drug List

UsageAppears throughout the document to indicate formulary status and override procedures.

SourcePrime Therapeutics Preferred Drug List

inv-93: Preferred Drug List description (alternate chunk).

DescriptionThe PDL lists drugs by therapeutic class and designates them as PREFERRED, NON-PREFERRED, or NON-PREFERRED WITH CRITERIA; it guides point-of-sale edits.

AuthorityManaged/implemented by Prime Therapeutics on behalf of the payer; effective implementation dates determine claim edits.

Provider ActionProviders should reference the PDL and may contact the help desk for overrides.

inv-94: Preferred — drugs listed as preferred are favored at point-of-sale.

Point-of-sale impactDrugs listed as Preferred are the formulary choices favored at point-of-sale.

CoveragePreferred listing implies coverage as the first-line formulary option within the class.

ReferenceExamples shown in PDL Preferred sections for multiple classes.

inv-95: Non‑Preferred — drugs listed under NON‑PREFERRED or INCLUDE BUT NOT LIMITED TO are subject to override and point-of-sale edits.

DefinitionNon‑Preferred drugs are listed under 'NON‑PREFERRED' or 'INCLUDE BUT NOT LIMITED TO' and may trigger point-of-sale edits or require an override.

OverridePrescribers may request an override via the Prime Therapeutics help desk (1-800-424-7895).

New ProductsNew products in a reviewed class default to non-preferred pending committee review.

inv-96: Preferred Drug List definition reiterated.

DefinitionPreferred Drug List (PDL) — formulary list used to designate preferred and non-preferred medications for coverage and claims editing.

FunctionDetermines adjudication at point-of-sale based on status and effective dates.

AccessMost up-to-date PDL available at Prime Therapeutics provider documents URL.

inv-97: PREFERRED label — shorthand key/value.

LabelPREFERRED

MeaningIndicates formulary preferred status on the PDL.

UseShown as a shorthand heading in each drug class section.

inv-98: 'INCLUDE BUT NOT LIMITED TO / NON-PREFERRED' key/value designation.

LabelINCLUDE BUT NOT LIMITED TO / NON-PREFERRED

MeaningDenotes example listings of non-preferred products; not an exhaustive list and may trigger overrides.

ActionProviders should assume additional listed products may be non-preferred and follow override process if needed.

inv-99: Topical steroid potency classes — potency class labeling explained.

DefinitionTopical steroids are categorized by potency classes (Class 1 Superpotent through Class 7 Least Potent) for formulary placement.

PurposePotency classes group corticosteroids to align preferred listings by strength.

ReferencePDL topical steroid sections include class headings and preferred agent lists.

inv-100: Topical steroid potency classes — potency groupings (Class 5-7) explained.

Class 5 (Lower-Mid)Examples listed as preferred include betamethasone valerate 0.1% cream and fluocinolone 0.01% cream.

Class 6 (Mild)Examples include desonide 0.05% cream and fluocinolone 0.01% solution.

Class 7 (Least Potent)Examples include hydrocortisone 2.5% cream and hydrocortisone acetate 0.5% (OTC) as preferred.

inv-101: Preferred Drug List (PDL) key/value reiterated.

TermPreferred Drug List (PDL)

RoleFormulary document that directs preferred/non-preferred status and override processes.

Provider ResourceContact Prime Therapeutics help desk or provider documents site for details.

Note

Step Therapy and Prior Authorization Tables

Step therapy summary	Notes / Provider action
No explicit step therapy requirements stated in this document excerpt.
New products in a reviewed drug class are considered NON-PREFERRED until the committee has reevaluated the evidence; prescribers may request an override via the Prime Therapeutics State Government Solutions Help Desk (Toll Free 1-800-424-7895). Claims will be edited at point-of-sale on the effective implementation date.

Step therapy rule	Operational detail
New products in a reviewed drug class default to non-preferred status pending committee reevaluation.
Prescribers may request an override for non-preferred drugs by calling the Prime Therapeutics State Government Solutions Help Desk (Toll Free 1-800-424-7895) and choosing the PDL option; point-of-sale edits apply on the class effective date.

Step therapy expectation	Examples / implications
Certain non-preferred agents are listed 'with criteria', indicating they may require prior authorization or meet specific criteria before coverage.
Examples include APRETUDE, CABENUVA, MARAVIROC/SELZENTRY, SUNLENCA, YEZTUGO (listed as NON-PREFERRED - WITH CRITERIA); prescribers should follow PA/criteria pathways or request overrides as needed.

Step therapy guidance	Reference
Refer to the PDL Criteria Overview for class-specific step therapy details; some agents are preferred only in specific formulations or are brand-only.
Preferred and non-preferred designations (and any manual review requirements) are noted on the PDL; consult the Criteria Overview for step edits and manual review processes.

Step therapy default	Action for providers
New products in a reviewed drug class are considered NON-PREFERRED until the committee has reevaluated the evidence for the class and may trigger edits at point-of-sale.
Prescribers should request overrides via the Prime Therapeutics State Government Solutions Help Desk (Toll Free 1-800-424-7895) if coverage is required prior to committee review; check PDL Criteria Overview for specific step rules.

Step therapy status	Notes
New products in a reviewed drug class are treated as non-preferred until the committee reevaluates the class.
Claims for non-preferred drugs will be edited at point-of-sale per the effective implementation date; prescribers may request overrides via the Prime Therapeutics help desk (1-800-424-7895).

Step therapy policy	Provider instruction
No explicit step therapy requirements are specified; new products default to non-preferred status until reviewed by the committee.
If a non-preferred agent is clinically necessary, prescribers should contact the Prime Therapeutics State Government Solutions Help Desk (Toll Free 1-800-424-7895) to request an override; point-of-sale edits and potential denials are governed by the PDL effective dates.

Revision History and Effective Dates

2026-04-01PDL effective/implementation dateLatest

Preferred Drug List effective implementation date for point-of-sale edits set to 4/1/2026; claims will be edited at point-of-sale on that date.

2026-01-01Posted preferred status update

Tetracycline agents original posted preferred status noted as 1/1/2026 in the document listings.

2026-04-01Non-preferred with criteria effective date

Certain HIV agents listed as non-preferred with criteria (e.g., APRETUDE, CABENUVA, MARAVIROC/SELZENTRY, SUNLENCA, YEZTUGO) have an effective/criteria date of 4/1/2026.

Policy Summary

PayerCareSource

PolicyPreferred Drug List (PDL) — Analgesics and NSAIDs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionIf a prescribed drug is non-preferred, prescribers must call the Prime Therapeutics State Government Solutions Help Desk (1-800-424-7895) and choose the PDL option to request an override.

SourceLink

On This Page

OpenPayer

Preferred Drug List (PDL) — Analgesics and NSAIDs

Coverage Criteria and Formulary Designations

Procedure and Billing Codes

Provider Actions, Overrides, and Prior Authorization

Definitions and Key Terms

Initial Therapy Criteria

Continuation Therapy Criteria

Step Therapy and Prior Authorization Tables

Quantity Limits and Specific Product Notes

Site of Care and Billing Guidance

Background and Scope

Revision History and Effective Dates