Pharmacy Benefit Administrator

The North Carolina Department of Health and Human Services (NCDHHS) has implemented a new Pharmacy Benefit Administrator (PBA) solution for NC Medicaid Direct effective Saturday, May 2, 2026.

NCDHHS has contracted Prime Therapeutics State Government Solutions LLC (Prime Therapeutics) to support pharmacy benefit operations. This transition modernizes pharmacy services and enhances the experience for providers, pharmacies and beneficiaries across North Carolina.

What This Means for Providers

Providers and pharmacies can expect:

• Streamlined pharmacy benefit administration;
• Improved coordination across providers and pharmacies;
• Enhanced access to pharmacy program information;
• More efficient claims processing and prior authorization workflows; and
• Increased transparency across pharmacy operations.

PBA Services Now Available

Prime Therapeutics delivers a comprehensive set of pharmacy benefit services supported by advanced technology. NC Medicaid Direct continues to manage all clinical policies and reimbursement methodologies for Point-of-Sale (POS) pharmacy.

The Prime PBA supports:

• Formulary management;

• Drug rebate administration;

• Clinical programs;

• POS claims processing;

• Drug utilization review;

• Prior Authorization administration;

• PHP Lock-In Program Oversight;

• Reporting and analytics;

• Member services; and

• Specialty pharmacy support.

Accessing the Prime PBA Pharmacy Provider Portal

Providers can access pharmacy benefit information, resources, and tools through the NC MES Portal. 

• Select the “PBA Pharmacy Provider Portal” tile from the NC MES landing page to access the portal.
• Some information is available without logging in; additional functionality requires secure login
• Training materials, announcements, and operational guidance are available on the portal

Providers should discontinue use of NCTracks pharmacy benefit functionality and transition fully to the PBA Pharmacy Provider Portal.

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 Pharmacy Benefit Administrator (PBA) Pharmacy Provider Portal;
• Select  Resources, followed by Forms and Documents,
• and finally, PA Clinical Criteria.

Pharmacy Claims Submission

As pharmacies submit point of sale (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 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 Submission Support

For pharmacy claims, prior authorization and portal support for NC Medicaid Direct, providers can contact the Pharmacy Benefit Administrator, Prime Therapeutics:

Pharmacy Help Desk (24/7): 1-844-620-6116
Web Support Hours: Monday-Friday, 8:00 AM to 8:00 PM ET
Fax: 1-866-422-8981