How do I know if a drug is covered?
You can search for specific medication in a look-up tool. If you need more information, contact Member and Recipient Services toll-free at 1-800-962-9003, Monday-Saturday, 7 a.m. to 6 p.m., to find out if a drug is covered.
The list of drugs covered by Vaya and approved by NC Medicaid is called the Preferred Drug List. 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 list of all medications covered by NC Medicaid.
What are the formulary tiers?
Within the Preferred Drug List (PDL), each medicine is assigned a tier, or a level of coverage. While all medicines are covered at the same copay for Medicaid members, Vaya Health 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 Health members within the limits of the Food and Drug Administration (FDA).
- Excluded – This tier of medications is not covered by NC Medicaid. State and federal law ban Vaya Health from covering these medications, even with prescriber approval.
How much will my medicine cost?
For Medicaid members, your prescriptions will be $4 or less. For NC Health Choice members, copays are $10 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. Further help is available through Member and Recipient Services at 1-800-962-9003.