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2005 North Carolina
Teachers’ and State
Employees’ Comprehensive
Major Medical
Preferred Drug List

Please bring this list
with you to every
doctor visit.

2005 Medco Health Solutions, Inc. All rights reserved.
Medco is a registered trademark of Medco Health Solutions, Inc.
If you have questions about your prescription drug benefit, visit www.medco.com or call Member Services.
WHAT IS A PREFERRED DRUG LIST?
A preferred drug list is a list of medications covered by your prescription drug plan. The North Carolina
Teachers’ and State Employees’
drug list has been compiled by a committee of North Carolina
physicians and pharmacists organized by the plan. It includes medications made by most pharmaceutical
manufacturers and for a variety of conditions.
Using preferred medications can help you save money on your prescriptions. When you use a medicationon the preferred list, your co-payment (for up to a 34-day supply) will be: Generic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10
Brand-name drugs (without a generic equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25
Brand-name drugs (with a generic equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35
Nonpreferred brand-name drugs and other drugs as determined
by the Pharmacy & Therapeutics Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40
WHAT ARE MY CO-PAYMENTS?
(Up to a 34-day supply)
(35 – 68-day supply)
(69 –102-day supply)
equivalent)Brand-name drugs(with a generic equivalent)Nonpreferred brand-name drugs and other drugs as determined by the Pharmacy& Therapeutics Committee WHY SHOULD I USE GENERIC DRUGS?
All generic drugs are preferred medications. Ask your doctor to authorize generic substitution whenever
a generic alternative is available. You will save money using generic drugs, since the co-payment is $10
for a 34-day supply.
Generic drugs, like brand-name drugs, must meet established Food and Drug Administration (FDA) stan-dards of quality and purity to help ensure their safety and effectiveness. Generic versions have the exactsame active ingredients as their brand-name counterparts, and they are equal in strength and dosage.
Sometimes drug manufacturers use different inactive ingredients, such as fillers and dyes, to provide adrug’s shape, color, size, and taste. By prescribing generics and preferred brand names, your doctor can help you save money. Remember tobring this list with you each time you visit your doctor.
Please note: This is not a complete list of preferred drugs. In some cases, the Plan may have certain
coverage limits. Some drugs require prior authorization or may be subject to quantity limits. Refer to
your benefit materials or call 1 800 336-5933 for specific coverage information. You can also refer
to www.statehealthplan.state.nc.us for a complete preferred list. This list is subject to change.
The information herein was current at the time of printing and is subject to change.
THERAPEUTIC DRUG CATEGORIES
$35.00 Co-pay
$35.00 Co-pay
ANTINEOPLASTICS AND
IMMUNOSUPPRESSANTS
$35.00 Co-pay
Miscellaneous
$10.00 Co-pay
$10.00 Co-pay
are covered under the Rx benefit, $25.00 Co-pay
$25.00 Co-pay
BLOOD MODIFIERS
Beta-Blockers
Beta and Alpha Blockers
$35.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
Anticoagulants
Myasthenia Gravis
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
acebutolol
CENTRAL NERVOUS SYSTEM
$35.00 Co-pay
$10.00 Co-pay
Alzheimer’s Disease
$25.00 Co-pay
Parkinson’s Disease
$25.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
Blood Cell Formation
$35.00 Co-pay
$25.00 Co-pay
Analgesics
$10.00 Co-pay
$25.00 Co-pay
Platelet Aggregation Inhibitors
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
Calcium Channel Blockers
$35.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
Miscellaneous
$10.00 Co-pay
$25.00 Co-pay
Seizures
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$35 Co-pay
$25.00 Co-pay
CARDIOVASCULAR
$35.00 Co-pay
$25.00 Co-pay
ACE Inhibitors
$10.00 Co-pay
Diuretics
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
DERMATOLOGY
Alpha-Blockers
Acne Vulgaris
$10.00 Co-pay
$10.00 Co-pay
Lipid-Lowering Agents
$35.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
Angiotensin II Receptor Blockers
$10.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
Migraine
Antiarrhythmics and
$25.00 Co-pay
Cardiac Glycosides
$10.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
Nitrates
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
Bacterial Infections
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan THERAPEUTIC DRUG CATEGORIES (CONT.)
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
Corticosteroids
$35.00 Co-pay
Inflammatory Bowel Disease
$10.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
EAR, NOSE & THROAT
$25.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
Pancreatic Enzymes
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
Growth Hormone
$40.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
Miscellaneous
$35.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
Depigmenting and
Repigmenting Agents
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
GASTROINTESTINAL
$25.00 Co-pay
Diarrhea
$10.00 Co-pay
INFECTIOUS DISEASES
$35.00 Co-pay
$25.00 Co-pay
Antibacterials
ENDOCRINOLOGY
$35.00 Co-pay
$25.00 Co-pay
Adrenal Corticosteroids
$10.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
Gastroesophageal Reflux
$25.00 Co-pay
Disease (GERD)
$10.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
Diabetes Mellitus
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
Gastrointestinal Spasm
$10.00 Co-pay
$35.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan THERAPEUTIC DRUG CATEGORIES (CONT.)
$35.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
30 mcg estrogen
Transdermal
$10.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
norgestrel/EE 0.3/30
$25.00 Co-pay
Progestins
$10.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
MUSCULOSKELETAL
$25.00 Co-pay
$35.00 Co-pay
Arthritis
$35.00 Co-pay
Antifungals
35 mcg estrogen
$10.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
Anti-Estrogens
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
Infertility
Antivirals
$40.00 Co-pay
$10.00 Co-pay
50 mcg estrogen
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
desogestrel/EE
$25.00 Co-pay
$40.00 Co-pay
$35.00 Co-pay
Vaginal Infections
$40.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
Progestin
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
Miscellaneous
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
OPHTHALMIC
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
Endometriosis
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
Anti-Inflammatories
$25.00 Co-pay
$10.00 Co-pay
Hormone Therapy/Menopause
$35.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
Contraceptives
Miscellaneous
$10.00 Co-pay
$10.00 Co-pay
20 mcg estrogen
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan THERAPEUTIC DRUG CATEGORIES (CONT.)
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$40.00 Co-pay
SUPPLEMENTS
Bipolar Disorder
$35.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
Potassium
$25.00 Co-pay
$10.00 Co-pay
RESPIRATORY DRUGS
Asthma/COPD
$35.00 Co-pay
Infections
Depression
$10.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
Vitamins and Minerals
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
UROLOGICAL
$35.00 Co-pay
$35.00 Co-pay
$25.00 Co-pay
Symptomatic Benign
Prostatic Hypertrophy
Glaucoma
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$10.00 Co-pay
$10.00 Co-pay
Insomnia
$25.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
Miscellaneous
Narcolepsy
$10.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
Miscellaneous
$10.00 Co-pay
Obsessive Compulsive Disorder
$25.00 Co-pay
$10.00 Co-pay
$25.00 Co-pay
Antitussives, Decongestants, and
$35.00 Co-pay
$35.00 Co-pay
Expectorants
$25.00 Co-pay
$10.00 Co-pay
PSYCHIATRIC
$35.00 Co-pay
MISCELLANEOUS
$10.00 Co-pay
Panic Disorder
Anaphylaxis Emergency
$10.00 Co-pay
$25.00 Co-pay
Hyperphosphatemia
$25.00 Co-pay
$25.00 Co-pay
$25.00 Co-pay
$35.00 Co-pay
$35.00 Co-pay
$40.00 Co-pay
$25.00 Co-pay
Premenstrual Dysphoric Disorder
$25.00 Co-pay
$25.00 Co-pay
Attention Deficit Hyperactivity
$35.00 Co-pay
Disorder
Psychosis
$10.00 Co-pay
$10.00 Co-pay
Smoking Deterrents
$10.00 Co-pay
$35.00 Co-pay
2005 North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan

Source: http://www.uncg.edu/hrs/pdlist.pdf

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