Pharmacy
Nebraska Total Care is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Nebraska Total Care members. Nebraska Total Care covers prescription medications and certain over-the-counter medications with a written order from a Nebraska Total Care provider. The pharmacy program does not cover all medications. Some medications may require prior authorization and some may have limitations. Other medically necessary pharmacy services may be covered as well.
- Nebraska Medicaid Pharmacy Reference Guide (PDF)
- Nebraska Medicaid Preferred Drug List (PDF), effective October 1, 2018
- Nebraska Total Care Medicaid Formulary List (PDF), effective September 1, 2018
- Nebraska Claim Limits (PDF)
- Nebraska Total Care Specialty Pharmacies (PDF)
Prior Authorization Process (PDF)
Prior Authorization Forms:
- Buprenorphine/Naloxone (PDF)
- Buprenorphine Consent (PDF)
- Glucagon-Like Peptide-1 Receptor Agonists (PDF)
- Insulin-Like Growth Factor (PDF)
- Low/Non-Sedating Antihistamines (PDF)
- NSAIDs: Cox I (PDF)
- Proton Pump Inhibitors (PDF)
- Quantity Limit or High Dose Override (PDF)
- Growth Hormone (PDF)
- Hepatitis C (PDF)
- Amylinomimetic Agents (PDF)
- Prior Authorization Medical Necessity (PDF)
- Brand Only Request (PDF)
- Youth Psychotropic Initiative (PDF)
- Synagis Prior Authorization Form (PDF)
- Specialty Medication Drug List (PDF)
- Nebraska Smoking Cessation Benefits (PDF)
- Mac Pricing Dispute
- Lock-in Provider Agreement (PDF)
- Lock-in Criteria (PDF)
- Nebraska Tobacco Quitline Fax Referral Form - English (PDF)
- Nebraska Tobacco Quitline Fax Referral Form - Spanish (PDF)
- Nebraska Tobacco Quitline Flow Chart (PDF)
Contact Us
CVS-Caremark
Phone: 1-888-321-2351
Envolve Pharmacy Solutions
Phone: 1-844-330-7852
Fax: 1-866-399-0929
Nebraska Total Care
Phone: 1-844-385-2192