Use the prescription drug search tool to find medications you need. The tool will show whether NC Medicaid covers the medicine and other important details.
How do I know if a drug is covered?
The list of drugs Vaya Health covers and NC Medicaid has approved is called the Preferred Drug List (PDL). This list includes a wide selection of generic and brand-name medicine to make sure you can get the medication you need.
The PDL is not a full list of all medications covered by NC Medicaid. To know if your medicine is covered, review the PDL or use the search tool above.
What are the formulary tiers?
Each medicine on the PDL is assigned a tier (a level of coverage). Medicaid members pay the same copay for all medicines, but Vaya and NC Medicaid promote the use of preferred medication when it is right for you.
The tiers are:
- PDL Preferred – This tier includes medications that are more cost-effective for the NC Medicaid Managed Care program.
- PDL Non-Preferred – This tier mostly consists of moderate-cost generic and brand-name prescription medications. You can get these medications when you have tried the PDL preferred medicine and it does not work for you, or if your prescriber says the preferred medicines are not right for you.
- Non-PDL – This tier includes medicines that NC Medicaid does not manage through the PDL because they do not fall within a PDL category. These medications are covered when they are part of the Medicaid Drug Rebate Program. These medicines are available to Vaya members within the limits set by the U.S. Food and Drug Administration.
- Excluded – This tier of medications is not covered by NC Medicaid. State and federal law ban Vaya from covering these medications, even with prescriber approval.
How much will my medicine cost?
For Medicaid members, your prescriptions will be $4 or less. If you are not able to afford your copay at the time you pick it up, the pharmacy may be able to give you the medicine and bill you later. You should not have to go without your medicine because you cannot afford your copay.
Are there any limits on medicine?
Some medications are limited. The amount you can get may be limited. You may also need to try other medication before you can get certain medicine. Your doctor may need to provide information on why a medicine is right for you.
The limits you may see include:
- Prior Authorization – Your prescriber may prescribe a drug that requires a review before the pharmacy is able to fill it. The review makes sure the drug is the safest, most effective, and most cost-efficient option for you before you start taking it. This review is called a prior authorization. The prior authorization process is conducted by a clinical pharmacy team. Please see the Find a Drug webpage to see if your medicine requires prior authorization. Pharmacy clinical coverage criteria are available for review on the NC Medicaid website.
- Quantity Limit – You may be able to get only a limited amount of a medication every month. Quantity limits help make sure the medication is safe for your clinical condition. They also help make sure you are using the least amount of tablets necessary for your condition. Please see the Find a Drug webpage to see if your medicine has a quantity limit.
- Generic Substitution – NC Medicaid requires the use of generic medication, when available, unless your prescriber says the brand name is medically necessary. In some cases, NC Medicaid may prefer the brand name instead of the generic medication. Please see the Preferred Drug List for more details.
