NC Medicaid: Outpatient Pharmacy Services (2024)

Notice of Changes to Pharmacy Benefits as of July 1, 2021

On July 1, 2021, certain beneficiaries were enrolled in NC Medicaid Managed Care health plans, which include the beneficiary’s pharmacy benefits. The information in the chart below will assist enrolled pharmacies in billing point of sale pharmacy claims for these beneficiaries. Also effectiveJuly 1, 2021, any claims that are submitted to our legacy pharmacy processor, NCTracks, for beneficiaries enrolled in managed care plans will reject with the information necessary to process pharmacy claims for these members. Pharmacies should direct any questions about claims for beneficiaries enrolled in a managed care health plan to that member’s health plan. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct.

Pharmacy Help Desk Contact Information

• AmeriHealth Caritas: 866-885-1406
• Carolina Complete Health: 833-992-2785
• Healthy Blue: 833-434-1212
• United Healthcare: 855-258-1593
• WellCare: 866-799-5318, option 3
• NCTracks: 800-688-6696

Tailored Plan Benefits Information, Effective as of July 1, 2024

Tailored Plan Pharmacy Help Desk Contact Information, Effective as of July 1, 2024

NC Medicaid Managed Care Pharmacy Summit Tailored Plan Roll Out Webinar

Watch the Oct. 12, 2022 Tailored Pan Roll Out Webinar here.

• Slides
• FAQs

About the Pharmacy Program

The North Carolina Medicaid Pharmacy Program offers a comprehensive prescription drug benefit, ensuring low-income North Carolinians have access to the medicine they need. Program management through stakeholder collaboration, effective use of drug rebates and careful selection of drugs on a Preferred Drug List (PDL) are just three waysNC Medicaidprovides access to the right drugs at the most advantageous cost. The result is a Pharmacy Program with the best overall value to beneficiaries, providers and the state.

• Outpatient Pharmacy Policies(9,9A,9B, 9Dand9E)
• Beneficiary Management Lock-In Program

Preferred Drug List

TheNC Medicaid Preferred Drug List (PDL)allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. The PDL was authorized by the NC General AssemblySession Law 2009-451, Sections 10.66(a)-(d).

• Prescribers are encouraged to write prescriptions for “preferred” products.
• Prescribers may continue to write prescriptions for drugs not on the PDL.
• If a prescriber deems that the patient’s clinical status necessitates therapy with a non-preferred drug, the prescriber will be responsible for initiating a prior authorization request.
• Prior authorization requirements may be added to additional drugs in the future.
• Submit Proposed Clinical Policy Changes to the PDL
• Preferred Drug List Review Panel
• Preferred Drug List (PDL) and Supplemental Rebate Program Annual Report SFY 2021 | PDLAnnual Report Archive

Prior Approval

• Prior Approval Drug Requests
• ASAP and A+KIDS Prior Approval

Behavioral Health Clinical Edits Criteria

Behavioral Health Clinical Edit Resolution: Submission Clarification Code 10

Bypassing the edit will require an override (SCC 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit.

Pediatric and Adult Edits Criteria are located at the bottom of the Prior Approval Drugs and Criteria page on NCTracks.

Tamper-resistant Prescription Pads

All written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry-recognized security features from each of the three categories of characteristics:

• One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form
• One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber
• One or more industry-recognized features designed to prevent the use of counterfeit prescription forms

Calling Prescribers on Non-compliant Prescriptions

If a pharmacist is presented with a prescription that does not meet the tamper-resistant prescription pad requirements and elects to call the prescriber to verify the prescription by telephone, the pharmacist must document the following information on the prescription:

• Initials of pharmacy staff verifying the prescription
• Date the prescription was verified
• First and last name of the individual (representing the prescriber) who verified the prescription

Reimbursem*nt

• Point-of-Sale (POS) Vaccine Rate Listings and Catalogs
• NADAC Weekly Files and NADAC Week to Week Comparison files
• NADAC Methodology (Part II) and NADAC Help Desk contact information
• NC Clotting Factor Non-340-B SMAC Rates
• Pharmacy Provider Generic Dispensing Rate Report
• State Maximum Allowable Cost (SMAC) List

Effective Nov. 3, 2022, NC Medicaid Pharmacy Fee Schedules are located in the Fee Schedule and Covered Code site.

Diabetic Testing and CGM fee schedules prior to Nov. 3, including archives, are available at the links below.

• Diabetic Testing and CGM Supplies - Oct. 13, 2022 - EXCEL
• Diabetic Testing and CGM Supplies - Oct. 13, 2022 - PDF
• Diabetic Testing and CGM Supplies - Sep. 7, 2022 - EXCEL
• Diabetic Testing and CGM Supplies - Sep. 7, 2022 - PDF
• Diabetic Testing and CGM Supplies - July, 15, 2022 - EXCEL
• Diabetic Testing and CGM Supplies - July, 15, 2022 - PDF

Forms

• Mirena Abandoned Unit Form
• Pharmacy Provider Enrollment
• Pharmacy Prior Approval
• State Maximum Allowable Cost (SMAC) Pricing Inquiry Worksheet

Opioid Analgesics and Combination Therapy

• North Carolina Multidisciplinary Collaboration on Opioid Use and Misuse
• Preferred Drug List Opioid Analgesics and Combination Therapy Daily MME (May 2018)
• Prior Approval Criteria for Opioid Analgesics
• Non-Opioid Alternatives(June 2018)
• NC Medicaid Opioid Safety - STOP Act Crosswalk (June 2018)
• FAQ on Naloxone Standing Order (August 2017)
• Provider Considerations for Tapering of Opioids

Medication Coverage Restriction Lists

Current

• March 2024

Archived

• Sept. 2023
• Sept. 2022
• March 2022

More Information

• Expansion Member Next Steps Flyer
• Expansion Member Next Steps for New Script
• Drug Utilization Review Board
• NADAC-FAQ

OTC COVID 19 Tests for Home Use

• Coverage Guidance
• Covered Tests - Jan. 2024

Pharmacy Newsletters

• 2024 Pharmacy Newsletters
• 2023 Pharmacy Newsletters
• 2022 Pharmacy Newsletters
• 2021 Pharmacy Newsletters
• 2020 Pharmacy Newsletters
• 2019 Pharmacy Newsletters
• 2018 Pharmacy Newsletters
• 2017 Pharmacy Newsletters
• 2016 Pharmacy Newsletters
• 2015 Pharmacy Newsletters
• 2014 Pharmacy Newsletters

Contact

NC MedicaidClinical Section
Phone: 919-855-4260
Fax: 919-715-1255
Email: medicaid.pdl@dhhs.nc.gov