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

Contact Information

Fee for Service (Medicaid Direct)NCTracks610242781640064N/A800-688-6696
AmeriHealth Caritas NCPerformRx019595PRX00801N/A866-885-1406
BCBSNC - Healthy BlueCarelonRx020107NC8473833-434-1212
Carolina Complete HealthExpress Scripts003858MA2ERA833-750-4461
United Health CareOptum Rx6104944949ACUNC855-258-1593
WellCare Health PlansExpress Scripts003858MA2ESA866-799-5318,
option 3

Tailored Plan Benefits Information

Managed Care
 Organization

Corresponding
 PBM Processor

BIN Number

PCN

Group Number

Contact Information

AllianceNavitus610602MCDMedicaid: TPMC
NCHC: TPHC		1-855-759-9300
PartnersCVS Caremark025052MCAIDADVRX22AC1-866-453-7196
TrilliumPerform Rx019595PRX10811N/A1-866-245-4954
VayaNavitus610602MCDVAYARX1-800-540-6083

 

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).

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. 

Medication Coverage Restriction Lists

NC Medicaid Medication Coverage Restriction List - April 2025

Reimbursement

The most up to date fee schedules are located in the:

Opioid Analgesics and Combination Therapy

Forms

More Information

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)

Archive

Newsletters

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

Archived Information

Tab/Accordion Items

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

Contact

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

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This page was last modified on 05/02/2025