NC Medicaid provides coverage for drugs with rebate eligible, active National Drug Codes (NDCs) as determined in First Databank, subject to conditions as promulgated in DHB Clinical Coverage Policies, NC Medicaid bulletins and other published NC Medicaid guidance.
- Drug fee schedules may further limit coverage of particular drugs within the specified setting (e.g., physician’s office, retail pharmacy).
- Prior authorization may still be required where clinically appropriate.
- When clinically appropriate, and prior authorization is pending, pharmacists should override prior authorization requirements at point of sale and dispense a limited supply of medication.
- Certain drug categories, such as vaccines, CROFAB, COVID EUA therapies, and radiopharmaceuticals may also be covered under NC Medicaid – refer to Clinical Coverage Policy 9 and other published NC Medicaid guidance for further details on these exceptions.
Additionally, health plans (i.e., Standard Plans and Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans) must cover the same drug formulary as established by the Department, as stated in the Standard Plan contract in Section V.C.3.c.ii. and the Tailored Plan contract in Section V.B.2.iii.(iii).(b). This is also required by Section 5.(6)b of Session Law 2015-245 as amended by Session Law 2016-121, which states: “All PHPs shall be required to use the same drug formulary, which shall be established by DHHS.” Health plans must cover drugs, which are covered in the NC Medicaid Direct (fee-for-service) program.
Contact
NCTracks Call Center: 800-688-6696