The North Carolina Department of Health and Human Services (NCDHHS) has awarded a contract to Prime Therapeutics, LLC., to implement a new Pharmacy Benefits Administrator (PBA) solution for NC Medicaid Direct. The PBA will go live on Saturday May 2, 2026, modernizing pharmacy benefit operations across NC Medicaid.
The PBA will offer an advanced and streamlined system for managing pharmacy benefits, facilitating improved communication and coordination among healthcare providers, pharmacies and patients. It will enhance efficiency, transparency, and accessibility within the pharmacy network, ultimately resulting in better patient care, cost-effective medication management and a more seamless experience for all stakeholders.
PBA services include, but are not limited to, formulary management, drug rebates, custom clinical programs, the point of sale (POS) pharmacy claims processing system, Preferred Drug List (PDL) management, prospective and concurrent Drug Utilization Review (DUR), prior authorization services, Retrospective Drug Utilization Review (Retro-DUR), PHP Lock-in Program management, reporting and adjudication capabilities, full pharmacy benefit member services and specialty pharmacy benefits services.
The PBA system will:
- Support the Department’s transition from a sole fee-for-service model to a combination of fee-for-service and managed care model, with the ability to process drug rebates for North Carolina, including NC Medicaid Direct and NC Medicaid Managed Care health plans.
- Have a state-of-the-art Pharmacy call center and Automated Voice Response System for providers/beneficiaries to support NC Medicaid Direct.
- Have the capability to manage and evaluate data across the enterprise regarding pharmacy programs, business processes, analytics, and reporting across fee-for-service and managed care health plans. The PBA system will support operational, clinical, financial, business processes, data analytics and reporting.
- Support some of the pharmacy related processes required by the Department of Public Health (DPH).
NC Medicaid will post updates, training materials, and provider/member resources on the NC Medicaid website as the go-live date approaches.
