The North Carolina Department of Health and Human Services (NCDHHS), Division of Health Benefits (DHB), has implemented Prime Therapeutics State Government Solutions LLC (Prime Therapeutics) as the Pharmacy Benefit Administrator (PBA) for NC Medicaid Direct Point of Sale (POS) pharmacy benefits, effective May 2, 2026.
This transition only applies to NC Medicaid Direct POS pharmacy claims and does not apply to pharmacy claims from NC Medicaid Managed Care Plans. The Medicaid Managed Care Plans will continue to operate as normal.
Effective May 2, 2026
As pharmacies begin submitting POS claims, please be aware that the new PBA system fully aligns with NCPDP standards. Pharmacies are strongly encouraged to review the Payer Specification to ensure claims are submitted accurately and in accordance with National Council for Prescription Drug Programs (NCPDP) requirements.
NC Medicaid Direct POS pharmacy claims can continue to be submitted to BIN 610242 and PCN 781640064, which has been transitioned to Prime Therapeutics.
- This change only applies to beneficiaries enrolled in NC Medicaid Direct.
- No impact on members enrolled in NC Medicaid Managed Care plans.
Claims and Prior Authorization Transition Guidance
- All current and historical Medicaid Direct claims and prior authorizations have been transferred to Prime Therapeutics.
- All new prior authorization requests should be submitted directly to Prime Therapeutics.
Accessing Prior Authorization Clinical Criteria
- Providers can access Prior Authorization (PA) clinical criteria through the NC Medicaid Enterprise System (MES) Landing Page
- From the MES Landing Page, select the PBA Pharmacy Provider Portal tile;
- Select Resources, followed by:
- Forms and Documents, and PA Clinical Criteria.
Important Information
- NC Medicaid Direct continues to manage all clinical policies and reimbursement methodologies for the NC Medicaid Pharmacy Benefit. Provider reimbursement is not impacted by this transition.
- The State maintains full oversight of the pharmacy benefit program.
Accessing the PBA Pharmacy Provider Portal
Providers can access the PBA Pharmacy Provider Portal by selecting the Pharmacy Benefit Administrator tile through the NC Medicaid Enterprise System (MES) Landing Page. From the MES Landing Page, select Pharmacy Benefit Administrator (PBA) Pharmacy Provider Portal. Providers do not need to log in to view the following information:
- PBA updates
- Announcements
- Training materials
- Resources
Additional information is available on the NC Medicaid Pharmacy Benefit Administrator web page.
Providers should discontinue use of NCTracks pharmacy benefit functionality and utilize the PBA Pharmacy Provider Portal for pharmacy benefit-related activities.
Prior Authorization Processing
Prime Therapeutics processes prior authorization submissions 24 hours per day, 7 days per week, 365 days a year beginning May 2, 2026.
72-Hour Emergency Supply Available for Pharmacy Prior Authorization Drugs
Pharmacy providers are encouraged to use the 72-hour emergency supply allowed for drugs requiring prior authorization. Federal law requires that this emergency supply be available to NC Medicaid beneficiaries for drugs requiring prior authorization (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)).
Use of this emergency supply helps ensure timely access to medically necessary medications. The system will allow dispensing of an emergency supply when indicated, bypassing the prior authorization requirement.
To submit an emergency fill, use Submission Clarification Code (SCC) “13”. Copayments may apply. There is no limit to the number of times the emergency supply can be used.
Pharmacy Resources and Drug Look Up Tool now available on the Prime
Pharmacy Provider Portal
Providers can access pharmacy resources, including:
- NC Single State Preferred Drug List
- Drug Lookup Tools
- Prior authorization criteria
- Provider training materials
These resources will be available through the NC Medicaid Enterprise System (MES) Landing Page From the MES Landing Page, select Pharmacy Benefit Administrator (PBA) Pharmacy Provider Portal.
Pharmacy Claims Processing
Prime Therapeutics uses the existing BIN and PCN numbers, which remain unchanged from previous processing under NCTracks.
| Plan | Corresponding Processor | BIN Number | PCN | Group Number | Contact Information |
|---|---|---|---|---|---|
| NC Medicaid Direct | Prime Therapeutics | 610242 | 781640064 | N/A | (844) 620-6116 |
Support and Contact Information
Providers should contact Prime Therapeutics for pharmacy benefit assistance through the Prime Pharmacy Call Center at 844-620-6116.
The call center is available 24 hours a day, 7 days a week, 365 days a year and can assist with:
- General pharmacy support
- Medication dispensing questions
- System access issues
Prime Therapeutics Claims Processing Support
- Telephone Call Center: (844) 620-6116, Available: 24 hours / 7 days a week / 365 days a year
- Web Support: Monday – Friday, 8:00 a.m. – 8:00 p.m. EST
- Fax Number: (866) 422-8981
- Mail: Prime Therapeutics State Government Solutions, LLC
Attn: GV
P.O. Box 64811
St. Paul, MN 55164-0811 - Electronic Prior Authorization (ePA) via CoverMyMeds®: Prime CoverMyMeds