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 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.