Proposed Medicaid and NC Health Choice Policies

NCGS §108A-54.2 requires that the Department of Health and Human Services consult with and seek the advice of the North Carolina Physician Advisory Group and other professional societies and organizations in developing new or amended Medicaid clinical coverage policies. The law requires the Department to publish proposed new and amended clinical coverage policies on the Department's website and accept oral and written comments. All consultations and comments are considered. The Department has delegated to the Division of Health Benefits Division Director the authority to make the final decisions regarding clinical coverage policies.

Comments submitted to this website may be considered public record and may be disclosed to parties requesting such records, including the identifiable information that you provide in your comment.  You may submit your comment without providing any identifiable information.  Voluntarily providing identifiable information does not mean that you will be contacted about your comment.

The following proposed new or amended Medicaid and NC Health Choice clinical coverage policies are available for review. Comments on proposed polices may be submitted by clicking the email link next to each proposed policy. Comments and questions not specifically related to the proposed policy should not be sent to this Web address. The initial comment period for each proposed policy is 45 days. An additional 15-day comment period follows if a proposed policy is modified as a result of the initial comment period. If the adoption of a new or amended medical coverage policy is necessitated by an act of the General Assembly or a change in federal law, then the 45- and 15-day time periods shall instead be 30- and 10-day time periods.

Proposed Policy Date Posted Submit Comments

Comment Period Ends

3L, State Plan Personal Care Services  01/08/21 03/15/21
2021 Annual PDL 01/22/21 03/08/21
Prior Approval Criteria Hepatitis C Virus Medications 01/27/21 03/13/21
Outpatient Pharmacy Clinical Edits- BH- Pediatric 01/27/21 03/13/21
Outpatient Pharmacy Clinical Edits- BH- Adult 01/27/21 03/13/21
Prior Approval Criteria Systems (CGM) and Related Supplies 01/27/21 03/13/21
1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment 02/26/21 04/12/21
5A-2, Respiratory Equipment and Supplies 02/26/21 04/12/21
5A-3, Nursing Equipment and Supplies 02/26/21 04/12/21
9, Outpatient Pharmacy 02/26/21 04/12/21
1A-20, Sleep Studies and Polysomnography Services 02/26/21 04/12/21
1A-41, Office Based Opioid Treatment: Buprenorphine & Buprenorphine- Naloxone 02/26/21 04/12/21
1E-7, Family Planning 02/26/21 04/12/21
1G-2, Skin Substitutes 02/26/21 04/12/21
Prior Approval Criteria Antiparkinson's Agents - Ongentys 03/1/21 04/15/21
Prior Approval Criteria Lupus Medications - Nephritis 03/1/21 04/15/21
Prior Approval Criteria Epidiolex - Tuberous Sclerosis 03/1/21 04/15/21
Prior Approval Criteria Hetlioz - SMS Indicator  03/1/21 04/15/21
Prior Approval Criteria Monoclonal Antibody - Nasal Polyps Xolair 03/1/21 04/15/21
Prior Approval Criteria Immunomodulators -  DIRA 03/1/21 04/15/21
Prior Approval Criteria Cystic Fibrosis - Trikafta 03/1/21 04/15/21