The North Carolina Department of Health and Human Services has awarded a contract to Magellan Medicaid Administration, LLC to implement a new Pharmacy Benefits Management (PBM) solution, scheduled to launch in 2025. Magellan Medicaid Administration, LLC was selected after careful evaluation of multiple proposals received in response to the publicly posted PBM Request for Proposal (RFP).
The new PBM solution in North Carolina will enhance the overall pharmacy benefit management system by improving the safety, efficiency, accessibility and affordability of pharmacy benefits for people and providers across the state.
As the PBM vendor, Magellan Medicaid Administration, LLC will work closely with NCDHHS to ensure that the PBM solution will:
- Streamline Prescription Processing: The PBM solution will simplify and expedite the processing of prescription claims, making it more efficient for patients, pharmacists and health care providers.
- Manage Costs: The new solution will focus on cost management strategies, such as negotiating drug pricing with manufacturers, maintaining the State’s Single Preferred Drug List, and exploring opportunities for more cost-effective drug utilization, ultimately aiming to reduce overall health care costs for beneficiaries and the state.
- Improve Access to Medications: The PBM solution will work toward ensuring beneficiaries have improved access to necessary medications by collaborating with a wide network of pharmacies and health care providers across the state.
- Enhance Medication Safety and Quality: The new solution will prioritize medication safety and quality by implementing advanced systems for drug utilization review, medication therapy management and proactive identification of potential drug interactions.
- Educate and Support Beneficiaries: The PBM solution will also provide educational resources and support to beneficiaries, offering guidance on medication adherence, potential side effects and available assistance programs to ensure beneficiaries receive the most benefit from their prescribed medications.
In preparation for the transition to the new PBM solution, providers are encouraged to:
- Stay informed. Review the NC Medicaid Provider webpage often and read all new Medicaid bulletins.
- Participate in educational opportunities. Respond to opportunities to learn more about the PBM solution, including participating in webinars and other events, to be fully prepared for the new system.
Providers will have several responsibilities when it comes to the new PBM solution in North Carolina. These responsibilities include:
- Prescription Submission: Providers will be responsible for accurately submitting prescriptions electronically to the PBM solution, ensuring that all necessary beneficiary information and medication details are included.
- Prior Authorization: In cases where certain medications require prior authorization, providers will need to initiate and complete the necessary authorization process with the PBM solution. This may involve providing clinical documentation or other required information to support the need for the medication.
- Drug Utilization Review: Providers will need to actively participate in the drug utilization review (DUR) process conducted by the PBM vendor. This involves reviewing beneficiary medication history, potential drug interactions, therapeutic duplications and other factors to ensure safe and appropriate medication use.
- Lock-in Program: The PBM vendor will administer the Lock-in Program according to Medicaid policy.
- Clinical Guidance: Providers may collaborate with the PBM vendor to receive clinical guidance and support related to medication therapy management, medication adherence and other aspects of beneficiary care. They may also communicate with the PBM vendor regarding patient-specific issues or concerns.
- Continuous Communication: Providers are encouraged to maintain open and ongoing communication with the PBM vendor and NCDHHS, sharing feedback, reporting any issues or challenges and staying updated on any changes or updates to the PBM system through established communication channels. This includes the web portal and call center.
By fulfilling these responsibilities, providers play a crucial role in ensuring the smooth operation and effectiveness of the new PBM solution in North Carolina, ultimately contributing to improved beneficiary care and outcomes. The PBM solution will be responsible for the complete pharmacy benefits functionality including point-of-sale pharmacy benefits, drug rebates (enterprise-wide) and DUR (enterprise-wide).
Medical claims will continue to process as they currently do in NCTracks. When the PBM solution goes live, pharmacy functionality in NCTracks, including call center, will be transitioned to the PBM solution. There should be no disruptions to beneficiaries or providers.
For additional information, visit the NC Medicaid Pharmacy Benefits Management webpage.
NC Medicaid Contact Center; 888-245-0179