NC Medicaid: Outpatient Pharmacy Services

About the Pharmacy Program

The North Carolina Medicaid Pharmacy Program offers a comprehensive prescription drug benefit, ensuring low-income North Carolinians have access to the medicine they need. Program management through stakeholder collaboration, effective use of drug rebates and careful selection of drugs on a Preferred Drug List (PDL) are just three ways NC Medicaid provides access to the right drugs at the most advantageous cost. The result is a Pharmacy Program with the best overall value to beneficiaries, providers and the state.

Outpatient Pharmacy Services

Standard Plan Benefits Information

Effective July 1, 2021, any claims that are submitted to our legacy pharmacy processor, NCTracks, for beneficiaries enrolled in managed care plans will reject with the information necessary to process pharmacy claims for these members. Pharmacies should direct any questions about claims for beneficiaries enrolled in a managed care health plan to that member’s health plan. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in NC Medicaid Direct.

Managed Care Organization	Corresponding PBM processor	BIN Number	PCN	Group Number
Fee for Service (Medicaid Direct)	NCTracks	610242	781640064	N/A
AmeriHealth Caritas NC	PerformRx	019595	PRX00801	N/A
BCBSNC - Healthy Blue	CarelonRx	020107	NC	8473
Carolina Complete Health	Express Scripts	003858	MA	2ERA
United Health Care	Optum Rx	610494	4949	ACUNC
WellCare Health Plans	Express Scripts	003858	MA	2ESA

Pharmacy Help Desk Contact Information

AmeriHealth Caritas: 866-885-1406
Carolina Complete Health: 833-750-4461
Healthy Blue: 833-434-1212
United Healthcare: 855-258-1593
WellCare: 866-799-5318, option 3
NCTracks: 800-688-6696

Tailored Plan Benefits Information

Managed Care Organization	Corresponding PBM Processor	BIN Number	PCN	Group Number(s)
Alliance	Navitus	610602	MCD	Medicaid: TPMC NCHC: TPHC
Partners	CVS Caremark	025052	MCAIDADV	RX22AC
Trillium	Perform Rx	019595	PRX10811	N/A
Vaya	Navitus	610602	MCD	VAYARX

Tailored Plan Pharmacy Help Desk Contact Information, Effective as of July 1, 2024

Tailored Plan Managed Care Organization	Pharmacy Help Desk Contact Information
Alliance Health	1-855-759-9300
Partners Health Management	1-866-453-7196
Trillium Health Resources	1-866-245-4954
Vaya Health	1-800-540-6083

NC Medicaid Managed Care Pharmacy Summit Tailored Plan Roll Out Webinar

Watch the Oct. 12, 2022 Tailored Plan Roll Out webinar here.

Preferred Drug List

The NC Medicaid Preferred Drug List (PDL) allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. The PDL was authorized by the NC General Assembly Session Law 2009-451, Sections 10.66(a)-(d).

Prescribers are encouraged to write prescriptions for “preferred” products.
Prescribers may continue to write prescriptions for drugs not on the PDL.
If a prescriber deems that the patient’s clinical status necessitates therapy with a non-preferred drug, the prescriber will be responsible for initiating a prior authorization request.
Prior authorization requirements may be added to additional drugs in the future.
Submit Proposed Clinical Policy Changes to the PDL
Preferred Drug List Review Panel
Preferred Drug List (PDL) and Supplemental Rebate Program Annual Report SFY 2021 | PDL Annual Report Archive

Prior Approval

Behavioral Health Clinical Edits Criteria

Behavioral Health Clinical Edit Resolution: Submission Clarification Code 10

Bypassing the edit will require an override (SCC 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit. Pediatric and Adult Edits Criteria are located at the bottom of the Prior Approval Drugs and Criteria page on NCTracks.

Tamper-resistant Prescription Pads

All written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry-recognized security features from each of the three categories of characteristics:

One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form
One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber
One or more industry-recognized features designed to prevent the use of counterfeit prescription forms

Calling Prescribers on Non-compliant Prescriptions

If a pharmacist is presented with a prescription that does not meet the tamper-resistant prescription pad requirements and elects to call the prescriber to verify the prescription by telephone, the pharmacist must document the following information on the prescription:

Initials of pharmacy staff verifying the prescription
Date the prescription was verified
First and last name of the individual (representing the prescriber) who verified the prescription

Reimbursement

Effective Nov. 3, 2022, NC Medicaid Pharmacy Fee Schedules are located in the Fee Schedule and Covered Code site.

Diabetic Testing and CGM fee schedules prior to Nov. 3, including archives, are available at the links below.

Forms

Opioid Analgesics and Combination Therapy

Medication Coverage Restriction Lists

Current

NC Medicaid Medication Coverage Restriction List - April 2025

Archived

More Information

OTC COVID 19 Tests for Home Use

Coverage Guidance
Covered Tests - September 2024

Inpatient/Outpatient Pharmacy Services

NC Select Drug List

North Carolina Medicaid maintains a NC Select Drug List. Drugs appearing on the NC Select Drug List shall be carved out of the inpatient DRG or outpatient RCC and claimed separately to allow the state to capture rebates.

Drugs appearing on the NC Select Drug List administered in an inpatient hospital setting shall be reimbursed directly to the hospital based on the ingredient component of the NC Select Drug at the Actual Acquisition Cost net of all discounts and rebates received by the hospital.
Drugs appearing on the NC Select Drug List administered in an outpatient hospital setting shall be reimbursed directly to the hospital based on the ingredient component of the NC Select Drug at the lesser of the Actual Acquisition Cost or Average Sales Price net of all discounts and rebates received by the hospital.
Drugs appearing on the NC Select Drug List administered in an outpatient professional setting shall be made directly to the provider based on the ingredient component of the NC Select Drug at the lesser of the Actual Acquisition Cost or Average Sales Price net of all discounts and rebates received by the provider.
Drugs on the NC Select Drug List are carved out of 340B. Providers may not utilize 340B inventory for NC Medicaid members for those drugs listed on the NC Select Drug List.

Please refer to the CMS website for the most current information regarding Average Sales Price (ASP).

Current

NC Select Drug List - (Effective May 2025)

Pharmacy Newsletters

Contact

NC Medicaid Clinical Section
Phone: 919-855-4260
Fax: 919-715-1255
Email: medicaid.pdl@dhhs.nc.gov

Tab/Accordion Items

AmeriHealth Caritas: 866-885-1406
Carolina Complete Health: 833-750-4461
Healthy Blue: 833-434-1212
United Healthcare: 855-258-1593
WellCare: 866-799-5318, option 3
NCTracks: 800-688-6696

Tab/Accordion Items

Watch the Oct. 12, 2022 Tailored Pan Roll Out Webinar here.