Pharmacy Benefit Manager

The North Carolina Department of Health and Human Services has awarded a contract to Magellan Medicaid Administration, LLC to implement the new Pharmacy Benefits Management (PBM) solution.

The PBM system 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 involved in process.  

PBM 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 PBM 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 the fee-for-service program and for 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 PBM system will support operational, clinical, financial, business processes, data analytics and reporting.  
  • Support some of the pharmacy related processes required by the Department of Mental Health (DMH) and the Department of Public Health (DPH).  

PBM will be operational in 2025.