Pharmacy Frequently Asked Questions (FAQs)

A provider shall not deny medications to a Medicaid member due to their inability to pay a copay or coinsurance.

The provider should open an account for the member, collect the amount owed at a later date, and document all attempts to collect the copay. If the account is not paid, the pharmacy may, in the course of normal accounting principles, write off the charges and stop monitoring the claim.

For more information regarding provider billing of patients who are Medicaid recipients, refer to 10A NCAC 22J .0106.

Prior authorization helps ensure medications are medically necessary and used appropriately and safely.

The provider will need to submit a request for approval to Medicaid. This request will include information about the member’s medical condition and why the medication is necessary.

Yes, if the member needs their medication(s) immediately while waiting for a prior authorization decision, the pharmacy can and should provide the member with a 72-hour emergency supply, if clinically appropriate. (Social Security Act, Section 1927, 42 U.S.C. 1396r-8(d)(5)(B)).

Yes, a copayment is required on 72-hour emergency supply.

For more information regarding copay, please refer to NC Medicaid Policy 9, Section 5.5 (Co-Payments).

No, there is no limit to the number of times the emergency supply can be dispensed by the pharmacy, while awaiting PA.

For more information regarding emergency supply, please refer to NC Medicaid Policy 9, Section 5.1 (Prior Authorizations).