This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
Effective Aug. 1, 2024, NC Medicaid beneficiaries may obtain the over the counter (OTC) oral contraceptive Opill without a prescription and at no cost.
While NC Medicaid encourages establishing care with a medical home, coverage without a prescription allows Medicaid beneficiaries easy access to the product and reduces barriers such as having to make an appointment to get a prescription, needing transportation to the appointment, or even a lack of health care providers in the community. Medicaid beneficiaries will be able to get Opill from pharmacies enrolled in Medicaid who will be able to submit the claim for reimbursement.
Coverage for NC Medicaid Managed Care Beneficiaries
This benefit, effective Aug. 1, 2024, applies to both NC Medicaid Direct beneficiaries and NC Medicaid Managed Care members. Claims for Opill without a prescription for all NC Medicaid beneficiaries, including NC Medicaid Direct and NC Medicaid Managed Care, should be adjudicated through NCTracks. The NC Medicaid Managed Care pharmacy benefit will not be utilized to process claims for Opill without a prescription.
NCTracks Claims Processor Information is below for Opill without a prescription.
| Enrollment | Claims Processor | Bin Number | PCN Number | Group Number |
|---|---|---|---|---|
| NC Medicaid Direct Beneficiaries | NCTracks | 610242 | 781640064 | N/A |
| NC Medicaid Managed Care Members | NCTracks | 610242 | 781640064 | N/A |
Please note: Opill is also covered with a prescription. For Opill with a prescription, pharmacies should continue to bill the beneficiary’s managed care plan if they are enrolled in managed care.
Pharmacy Providers
For Opill to be covered without a prescription by NC Medicaid, pharmacy providers should:
- Process all claims for Opill without a prescription through the NCTracks BIN, PCN and group number noted in the table above.
- Submit the claim using the pharmacy NPI as the prescriber to identify the claim is billing for “Opill without a prescription” coverage.
The claim will be denied with a message back to pharmacy, instructing the pharmacy to “resubmit the claim using “P0” (P zero) as the edit override code.” - Resubmit the claim using Professional Service Code “P0” to override edit 07006.
A $5.00 fee will be included in the reimbursement amount paid to the pharmacy. A dispensing fee will not be paid. Beneficiaries are allowed to obtain up to a 3-month supply of Opill with each request, without a prescription, with a maximum of 13 packs per year. Opill is a progestin only contraceptive. Pharmacists should counsel beneficiaries that Opill is most effective when taken once a day at the same time each day.
Pharmacy providers are permitted and encouraged to post signage in the pharmacy to inform Medicaid beneficiaries that Opill is available at no cost, without a prescription.
Contact
NCTracks Call Center: 800-688-6696