This bulletin updates the previously published NC Medicaid Direct Pharmacy Benefits Administrator Provider Transition Overview and Webinars bulletin.
Topics Related to Pharmacy Providers
The North Carolina Department of Health and Human Services (NCDHHS) reminds pharmacy providers that Prime Therapeutics State Government Solutions LLC (Prime Therapeutics) will serve as the Pharmacy Benefits Administrator (PBA) for NC Medicaid Direct point-of-sale (POS) pharmacy benefits beginning May 2, 2026.
NOTE: This change applies only to NC Medicaid Direct beneficiaries. There is no impact to beneficiaries enrolled in NC Medicaid Managed Care.OverviewThe North Carolina Department of Health and Human Services (NCDHHS) is transitioning Pharmacy Benefit Administrator (PBA) services for NC Medicaid Direct. Beginning May 2, 2026, Prime Therapeutics State Government Solutions LLC (Prime) will serve as the PBA for NC Medicaid Direct pharmacy claims.
Flexibilities extended through Feb. 6, 2026, for NC Medicaid beneficiaries due to additional Winter Storm weather.
Flexibility extended to Jan. 30, 2026, for NC Medicaid beneficiaries due to Winter Storm.
Flexibilities effective Jan. 23, 2026, to Jan. 26, 2026, for NC Medicaid beneficiaries due to Winter Storm.
This bulletin corrects Current Procedure Terminology (CPT) code tables initially published Dec. 30, 2025.
Effective Dec. 12, 2025, coverage for GLP-1s for the treatment of obesity will be reverted to the coverage available as of Sept. 30, 2025.
Recent court rulings now require the North Carolina Department of Health and Human Services to reverse provider rate reductions and restore rates to their Sept. 30, 2025, levels.
This guidance is based on the NC Immunization Program/Vaccines for Children guidelines.