Pharmacy Provider Frequently Asked Questions

Answer: A Pharmacy Benefit Administrator (PBA) is an organization contracted to administer the day-to-day operations of a pharmacy benefit for a health program. In NC Medicaid, the PBA will administer the Fee-for-Service pharmacy benefit.

The PBA will implement NC Medicaid policies and clinical criteria, adjudicate point-of-sale pharmacy claims, manage prior authorizations, maintain the Preferred Drug List (PDL), conduct drug utilization review (DUR), operate provider and member help desks and deliver reporting and analytics to support pharmacy operations.

In addition, the PBA will also coordinate with managed care plans and process drug rebates under the Medicaid Drug Rebate Program (MDRP).

Answer: The North Carolina Department of Health and Human Services has awarded the contract to Prime Therapeutics, formerly known as Magellan Medicaid Administration, LLC, to implement the new Pharmacy Benefits Administrator (PBA) solution.

Answer: NC Medicaid is transitioning the administration of the Fee-for-Service (FFS) pharmacy benefit from the current system (NCTracks) to a new Pharmacy Benefit Administrator (PBA) administered by Prime Therapeutics LLC. The new FFS PBA will launch on May 2, 2026. This change only affects FFS Medicaid beneficiaries; the managed care plans are not impacted by the new PBA and will continue to operate as they do today.

Answer: The NC Medicaid Fee-for-Service PBA will launch on May 2, 2026. Additional communications, webinar, training opportunities, and system access details will be provided prior to the Go-Live date to support members and providers.

Answer: There will be no change to the Managed Care Plans. This change only affects Fee-for-Service Medicaid beneficiaries. Beneficiaries who currently receive their Medicaid benefit through a Managed Care Plan will continue to receive their benefits from their managed care plan as they do today.

Answer: Prime Therapeutics will administer the NC Medicaid Fee-for-Service (FFS) pharmacy benefit. As the PBA, Prime will be responsible for adjudicating Point-of-Sale (POS) FFS pharmacy claims, managing pharmacy prior authorizations and supporting overall pharmacy benefit operations.

They will manage the Medicaid Drug Rebate Program (MDRP), oversee the Preferred Drug List (PDL) and provide drug utilization management. Additionally, Prime will develop State-approved clinical criteria for select drugs and conduct prospective and retrospective Drug Utilization Reviews (DUR). Other key responsibilities include pharmacy help desk support, member services help desk support and pharmacy reporting.

Answer: The Pharmacy Benefits Administrator (PBA) system will support the Department’s transition from a sole Fee-for-Service model to a combined Fee-for-Service and managed care model. The PBA system will feature a state-of-the-art pharmacy call center and an Automated Voice Response (AVR) System to assist providers and beneficiaries in Medicaid Direct.

Answer: This change primarily impacts pharmacies that submit claims for NC Medicaid Fee-for-Service (FFS) members and prescribers who request pharmacy prior authorizations for FFS members. Other provider types may be indirectly affected through changes to prior authorization workflows and related coordination with pharmacy benefit processes.