Pharmacy Provider Frequently Asked Questions
PBA General Information/Pre-Launch FAQs
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 pharmacy benefit for NC Medicaid Direct (fee-for-service).
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 beneficiary 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 NC Medicaid Direct (fee-for-service) pharmacy benefit from the current system (NCTracks) to a new Pharmacy Benefit Administrator (PBA) administered by Prime Therapeutics LLC. The PBA will launch on May 2, 2026.
This change only affects beneficiaries covered under NC Medicaid Direct. Medicaid beneficiaries enrolled in NC Medicaid Managed Care are not impacted by the new PBA and will continue to operate as they do today.
Answer: The 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 providers and beneficiaries.
Answer: There will be no change to the managed care health plans. This change only affects beneficiaries covered by NC Medicaid Direct. Beneficiaries who currently receive their Medicaid benefit through a managed care health plan will continue to receive their benefits from their managed care health plan as they do today.
Answer: Prime Therapeutics will administer the pharmacy benefit for NC Medicaid Direct. As the PBA, Prime will be responsible for adjudicating Point-of-Sale (POS) fee-for-service 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 NC Medicaid Direct.
Answer: This change primarily impacts pharmacies that submit claims for NC Medicaid Direct beneficiaries and prescribers who request pharmacy prior authorizations for NC Medicaid Direct beneficiaries. Other provider types may be indirectly affected through changes to prior authorization workflows and related coordination with pharmacy benefit processes.
PBA Post-Launch FAQs
- BIN: 610242
- PCN: 781640064
- Group – LEAVE BLANK
The unit of measure required on all incoming claims should be submitted using National Council for Drug Prescription Programs (NCPDP) Field 600-28 (e.g., EA, GM, ML).
If the pharmacy cannot locate this field, they should contact their software vendor for assistance or call Prime Therapeutics Call Center at 844-620-6116.
For NC Medicaid Provider Enrollment, the providers should contact the Enrollment Verification and Credentialing Center at 866-844-1113 or visit NCTracks for assistance.
The following table lists the NCPDP interactive Drug Utilization Review (DUR) Reason for Service, Professional Service, and Result of Service codes, which may be used to override ProDUR denials at the POS.
Note: If multiple DUR alerts are generated for a single claim, the pharmacist must provide a response for each individual alert.
Additional details can be found in the North Carolina Medicaid Direct Pharmacy Provider Manual.
| Reason for Override Code(s) | Provider Override Allowed? | Applicable Professional Service Code(s)/Description | Applicable Result of Service Code(s)/Description |
|---|---|---|---|
ER – Overuse Precaution DD – Drug-Drug Interaction TD – Therapeutic Duplication HD – High Dose PG – Drug to Pregnancy | Yes | M0: Prescriber Consulted P0: Patient Consulted R0: Pharmacist Consulted Other Source 00: No Intervention Blank: Not Specified | 1A: Filled, False Positive 1B: Filled Prescription as Is 1C: Filled with Different Dose 1D: Filled with Different Directions 1E: Filled with Different Drug 1F: Filled with Different Quantity 1G: Filled with Prescriber Approval 2A: Prescription Not Filled 2B: Prescription Not Filled – Directions Clarified |
Pharmacies should first attempt to resolve the DUR rejections using the returned DUR codes. If additional assistance is needed, please contact Prime Therapeutics at 844-620-6116.
COB is the mechanism used to designate the order in which multiple carriers are responsible for benefit payments and prevention of duplicate payments. Pharmacies should refer to the Coordination of Benefits section in the North Carolina Direct Pharmacy Provider Manual and the North Carolina Medicaid Direct NCPDP D.0 Payer Specifications Claim Billing for specific requirements.
NC Medicaid Direct is the payer of last resort. Pharmacies should bill all applicable third-party insurance carriers, including Medicare and commercial insurance plans, prior to submitting the claim to NC Medicaid Direct. If third-party coverage is identified, the primary payer must be billed first before submitting the claim to Medicaid as the secondary payer.
If the beneficiary cannot provide other insurance information or states they do not have other insurance coverage, pharmacies may submit appropriate Other Coverage Code (NCPDP field 308-C8) when applicable.
The Other Coverage Code (OCC) (NCPDP Field ID: 308-C8) is an NCPDP standard field on pharmacy claims that communicates whether a beneficiary has other insurance coverage and how that coverage was applied to the prescription. It allows payers to correctly coordinate benefits when more than one insurer may be responsible for payment.
Other Coverage Code (NCPDP Field ID: 308-C8) | Description |
|---|---|
| 0 – Not Specified | OCC 0 is used when the beneficiary does not have TPL. Additional COB fields should not be submitted when using this OCC |
| 1 – No Other Coverage | OCC 1 may be used when the pharmacy cannot determine the valid TPL identity. Additional COB fields should not be submitted when using this OCC. |
| 2 – Other Coverage Exists, Payment Collected | OCC 2 is used when any positive amount of money is collected from another payer. |
| 3 – Other Coverage Exists, Claim Not Covered | OCC 3 is used when the beneficiary has TPL, but the particular drug is not covered by the primary payer |
| 4 – Other Coverage Exists, Payment Not Collected | OCC 4 is used when a beneficiary’s TPL is active, but there is no payment collected from the primary insurer (e.g., the beneficiary has not met their primary payer’s deductible obligation, plan capitation, etc.). OCC 4 may also be used if the total cost of the claim is less than the beneficiary’s TPL co-pay requirement and the primary insurance plan made no payment. |
| 8 – Claim Billing for Co-Pay | OCC 8 is not allowed for claims submitted to NC Medicaid Direct. Claims submitted with an OCC 8 will deny NCPDP EC 13 – M/I Other Coverage Code and return the additional message “OCC = 8 Not accepted, please submit claim will OCC of 2 with valid other payer information.” |
The table below lists the OCC values and the required COB fields for each. Fields must be completed accurately to ensure they align with the OCC submitted, as required COB data elements may vary by OCC.
Note: Claims will deny if required fields are missing or contain invalid information.
| NCPDP Field Description & ID | OCC 2 | OCC 3 | OCC 4 | Comments |
|---|---|---|---|---|
| Other Payer Amount Paid (431-DV) | Yes | No | Yes | OCC 2: Must be > $0.00 OCC 4: Must be $0.00 |
| Other Payer Amount Paid Qualifier (342-HC) | Yes | No | Yes | |
| Other Payer-Patient Responsibility Amount Qualifier (351-NP) | Yes | No | Yes | |
| Other Payer-Patient Responsibility Amount (OPPRA) (352-NQ) | Yes | No | Yes | OCC 2: Must be ≥ $0.00 OCC 4: Must be > $0.00 |
| Other Payer Date (443-E8) | Yes | Yes | Yes | Must be compliant with timely filing: B1 and B2 Transactions: 365 days B3 Transactions: 18 months |
| Other Payer ID Qualifier (339-6C) | Yes | Yes | Yes | |
| Other Payer ID (340-7C) | Yes | Yes | Yes | |
| Other Payer Reject Code (471-6E) | No | Yes | No | Must be a valid NCPDP reject/error code |
| Other Payer Reject Count (471-5E) | No | Yes | No |
If a pharmacy claim is rejected due to Third-Party Liability (TPL), pharmacies should verify the member’s other insurance coverage and bill the identified third-party payer prior to submitting the claim to NC Medicaid Direct. If the primary payer returns a payment or denial response, the applicable COB/TPL information must be included on the Medicaid claim submission in accordance with NCPDP standards and Prime Therapeutics claim processing requirements.
If the beneficiary cannot provide insurance information or states they do not have other coverage, pharmacies may use the appropriate Other Coverage Code (NCPDP field 308-C8), when applicable, to process the claim for payment consideration.
Pharmacies should refer to Prime Therapeutics payer sheet and companion guide for TPL submission requirements, accepted override values, and claim processing instructions. If additional assistance is needed, pharmacies may contact Prime Therapeutics at 844-620-6116.
This page was last modified on 05/13/2026