This bulletin applies to NC Medicaid Managed Care.
Note: This bulletin replaces in full the Utilization Management by Managed Care Plans Aligned with Food and Drug Administration Labeling bulletin.
NC Medicaid Managed Care health plans are authorized to apply utilization management (UM) strategies such as prior authorization based on Food and Drug Administration (FDA)-approved indications and/or Medically Acceptable Indications when the State has not established specific clinical criteria and state policy does not prohibit clinical criteria for a drug or class of drugs.
This policy applies to drugs in the outpatient pharmacy, outpatient hospital and the Physician Administered Drug settings.
Outpatient Pharmacy: Point of Sale Pharmacy
NC Medicaid Managed Care plans may implement UM aligned with the FDA label and/or Medically Acceptable Indications in the following scenarios in Point of Sale (POS) pharmacy:
Preferred Drug List
- Beginning Jan. 1, 2026, to support current policy, each drug category on the NC Medicaid Preferred Drug List (PDL) will include a notation in red text when additional UM or prior authorization may not be applied by NC Medicaid Managed Care health plans.
- The red text will indicate the following: Plans may not apply additional utilization management or prior authorization criteria to this category.
- If no such red text appears, plans may apply UM consistent with FDA labeling and/or Medically Acceptable Indications.
Non-PDL Drugs
- Per Clinical Coverage Policy 9, drugs not listed on the PDL may be subject to UM based on FDA labeling and/or Medically Acceptable Indications only if there are no posted clinical criteria in Prime Therapeutics and state policy does not prohibit clinical criteria for a drug or class of drugs. Clinical Coverage Policy 9 can be found on the Program Specific Clinical Coverage Policies page, by selecting “9, Outpatient Pharmacy Program.”
- If clinical criteria are posted in Prime Therapeutics, plans must not apply additional UM beyond what is specified.
- Prime Therapeutics Pharmacy Clinical Criteria are available on NC Medicaid’s website.
Accessing POS Clinical Criteria
Providers should consult Prime Therapeutics for NC Medicaid Direct or the respective NC Medicaid Managed Care health plan’s website for posted clinical criteria. For NC Medicaid Managed Care health plans, refer to Health Plan Contacts and Resources.
Outpatient Hospital
Drugs administered in outpatient hospital settings may also be subject to UM based on the FDA label and/or Medically Acceptable Indications, when the state does not have posted clinical criteria in NCTracks and NC Medicaid policy does not prohibit clinical criteria for a drug or class of drugs.
Accessing Outpatient Hospital Clinical Criteria
Providers should consult NCTracks for NC Medicaid Direct or the respective NC Medicaid Managed Care health plan’s website for posted clinical criteria. For NC Medicaid Managed Care health plans, refer to Health Plan Contacts and Resources.
Physician Administered Drug Program
Drugs administered in the Physician Administered Drug Program may be subject to UM based on the FDA label and/or Medically Acceptable Indications, when NC Medicaid does not have posted clinical criteria. Per Clinical Coverage Policy 1B, effective July 1, 2026, NC Medicaid Managed Care health plans are permitted to apply UM to the Physician Administration Drug Program (PADP). The updated policy can be found on the Program Specific Clinical Coverage Policies page, by selecting “1B, Physician Administered Drug Program.”
Accessing Physician Administered Drug Clinical Criteria
Providers should consult NCTracks for NC Medicaid Direct or the respective NC Medicaid Managed Care health plan’s website for posted clinical criteria. For NC Medicaid Managed Care plans, refer to Health Plan Contacts and Resources.
Contact
NC Medicaid Direct
- Prime Contact Center: 844-620-6116
- NCTracks Contact Center: 800-688-6696
Standard Plans
- AmeriHealth: 866-885-1406
- Healthy Blue: 833-434-1212
- Carolina Complete: 833-750-4461
- United Healthcare: 855-258-1593
Tailored Plans
- Alliance Health: 855-759-9300
- Partners: 866-453-7196
- Trillium: 866-245-4954
- Vaya Health: 800-540-6083
Children and Families Specialty Plan
Healthy Blue Care Together: 833-777-3788
Related Topics:
This page was last modified on 08/10/2026