Pharmacy
Nebraska Medicaid Preferred Drug List
The medications on the Nebraska Medicaid Preferred Drug List (PDL) are covered by Nebraska Total Care. Non preferred drugs on this list may be covered when certain requirements are met. Other limitations for specific drugs may exist and are explained in the Nebraska Medicaid Claims Limitations (PDF).
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 Claim Limitations (PDF) (updated 10/1/2020)
- Nebraska Total Care Value-Add Formulary (PDF) (updated 10/1/2020)
- Nebraska Total Care Over-the-Counter Approved Products (Excel) (updated 10/08/2020)
- Nebraska Total Care Machine Readable Formulary (JSON)
- Nebraska Medicaid Preferred Drug List (PDL) (updated 10/1/2020)
- Nebraska Medicaid MAC Price Listing (PDF) (updated monthly)
- Nebraska Medicaid Pharmacy Reference Guide (PDF)
- Nebraska Total Care 90-Day Maintenance Drugs (Excel) (updated 04/01/2020)
- Pharmacy Update: Urgent Claims Processing Change (PDF) (effective 04/01/2019)
- Pharmacy Update: Heritage Health Adult Expansion Program (PDF) (effective 10/01/2020)
- RxAdvance MAC Appeals Pharmacy Portal Guide (PDF)
- RxAdvance Pharmacy Portal
- Medical Necessity Form (PDF)
- Buprenorphine Consent (PDF)
- Buprenorphine/Naloxone Prior Auth (PDF)
- CoverMyMeds Prior Auth Request
- Growth Hormone Prior Auth (PDF)
- Hepatitis C Prior Auth (PDF)
- Hereditary Angioedema (HAE) Prior Auth (PDF)
- Long-Acting Injectable (LAI) Prior Auth (PDF)
- Quantity Limit or High Dose Override Prior Auth (PDF)
- Synagis Prior Auth (PDF)
- Nebraska Total Care Specialty Pharmacies (PDF) (updated 3/29/2019)
- Nebraska Total Care Hemophilia Pharmacies (PDF) (updated 3/29/2019)
- Nebraska Total Care Specialty Medication Drug List (PDF) (updated 4/1/2019)
- Prior Authorization Medical Necessity (PDF)
- Nebraska Tobacco Quitline Fax Referral Instructions (PDF) (effective 8/1/2020)
- Nebraska Tobacco Quitline Fax Referral Form (PDF) (effective 8/1/2020)
- Nebraska Smoking Cessation Benefits (PDF)
Contact Us
RxAdvance Help Desk
Phone: 1-800-974-5268
Envolve™ Pharmacy Solutions
Prior Auth Phone: 1-844-330-7852
Prior Auth Fax: 1-877-386-4695
Nebraska Total Care
Phone: 1-844-385-2192, Nebraska Relay Service 711