Outpatient Pharmacy Services

Notice of Changes to Pharmacy Benefits as of July 1, 2021

Beginning July 1, 2021, certain beneficiaries will be enrolled in Medicaid Managed Care health plans, which will include the beneficiary’s pharmacy benefits. The information in the chart below will assist enrolled pharmacies in billing point of sale pharmacy claims for these beneficiaries. Also beginning July 1, 2021, any claims that are submitted to our legacy pharmacy processor, NC Tracks, for beneficiaries that are enrolled in managed care plans will reject with the information necessary to process pharmacy claims for these members. Pharmacies should direct any questions about claims for beneficiaries enrolled in a managed care health plan to that member’s health plan. All member ID numbers will be the same for the beneficiary whether they are enrolled in a health plan or in Medicaid Direct.

Managed Care Organization Corresponding PBM processor BIN Number PCN Group Number
Fee for Service (Medicaid Direct) NC Tracks 610242 781640064 N/A
AmeriHealth Caritas NC PerformRx 019595 PRX00801 N/A
BCBSNC - Healthy Blue IngenioRx (back end CVS Caremark) 020107 NC 8473
Carolina Complete Health Envolve (back end CVS Caremark) 004336 MCAIDADV RX5480
United Health Care Optum Rx 610494 4949 ACUNC
WellCare Health Plans CVS Caremark 004336 MCAIDADV RX8904

Pharmacy Help Desk Contact Information:

  • AmeriHealth Caritas: 1-866-885-1406
  • Carolina Complete Health: 1-833-992-2785
  • Healthy Blue: 1-833-434-1212
  • United Healthcare: 1-855-258-1593
  • WellCare: 1-866-799-5318, option 3
  • NC Tracks: 1-800-688-6696
     

About the Pharmacy Program

The North Carolina Medicaid Pharmacy Program offers a comprehensive prescription drug benefit, ensuring that low-income North Carolinians have access to the medicine they need. Program management through stakeholder collaboration, effective use of drug rebates and careful selection of drugs on a Preferred Drug List (PDL) are just three ways NC Medicaid provides access to the right drugs at the most advantageous cost. The result is a Pharmacy Program that the best overall value to beneficiaries, providers and the state.

Preferred Drug List

The NC Medicaid Preferred Drug List (PDL) allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. The PDL was authorized by the NC General Assembly Session Law 2009-451, Sections 10.66(a)-(d).

  • Prescribers are encouraged to write prescriptions for “preferred” products.
  • Prescribers may continue to write prescriptions for drugs not on the PDL.
  • If a prescriber deems that the patient’s clinical status necessitates therapy with a non-preferred drug, the prescriber will be responsible for initiating a prior authorization request.
  • Prior authorization requirements may be added to additional drugs in the future.
  • Submit Proposed Clinical Policy Changes to the PDL
  • Preferred Drug List Review Panel

Prior Approval

Tamper-resistant Prescription Pads

All written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry recognized security features from each of the three categories of characteristics:

  • One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form
  • One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber
  • One or more industry-recognized features designed to prevent the use of counterfeit prescription forms

Calling Prescribers on Non-compliant Prescriptions

If a pharmacist is presented with a prescription that does not meet the tamper-resistant prescription pad requirements and elects to call the prescriber to verify the prescription by telephone, the pharmacist must document the following information on the prescription:

  • Initials of pharmacy staff verifying the prescription
  • Date the prescription was verified
  • First and last name of the individual (representing the prescriber) who verified the prescription

Reimbursement

Forms

Opioid Analgesics and Combination Therapy

More Information

Pharmacy Newsletters

Contact

NC Medicaid Clinical Section
Phone: 888-245-0179
Fax: 919-715-1255
Email: medicaid.pdl@dhhs.nc.gov