The North Carolina Medicaid Pharmacy Program stands as a crucial healthcare safety net, dedicated to providing comprehensive prescription drug benefits to eligible low-income residents of North Carolina. This program emphasizes efficient management through collaborative stakeholder engagement, strategic utilization of drug rebates, and a carefully curated Preferred Drug List (PDL). These key strategies ensure that beneficiaries receive access to the medications they need at the most cost-effective prices, representing optimal value for patients, healthcare providers, and the state’s resources.
Navigating Outpatient Pharmacy Services with NC Medicaid
Standard Plan Pharmacy Benefits Explained
Starting July 1, 2021, changes were implemented to streamline pharmacy claims processing for individuals enrolled in managed care plans under NC Medicaid. Claims submitted through the legacy NCTracks system for managed care enrollees will be rejected, prompting pharmacies to utilize the specific processing systems designated for each Managed Care Organization (MCO). It is important for pharmacies to direct all claim-related inquiries for managed care beneficiaries directly to the member’s respective health plan. Beneficiary ID numbers remain consistent regardless of enrollment in a health plan or NC Medicaid Direct.
To ensure smooth claim processing, refer to the table below for details on PBM processors, BIN numbers, PCNs, and Group Numbers for different Managed Care Organizations:
| Managed Care Organization | PBM Processor | BIN Number | PCN | Group Number |
|---|---|---|---|---|
| Fee for Service (Medicaid Direct) | NCTracks | 610242 | 781640064 | N/A |
| AmeriHealth Caritas NC | PerformRx | 019595 | PRX00801 | N/A |
| BCBSNC – Healthy Blue | IngenioRx (CVS Caremark backend) | 020107 | NC | 8473 |
| Carolina Complete Health | Express Scripts | 003858 | MA | 2ERA |
| United Health Care | Optum Rx | 610494 | 4949 | ACUNC |
| WellCare Health Plans | Express Scripts | 003858 | MA | 2ESA |
For any immediate assistance or clarification regarding pharmacy claims and processes, dedicated help desks are available. Contact information for these resources can be found on the NC Medicaid official website or through provider support channels.
Understanding Tailored Plan Pharmacy Benefits
NC Medicaid also offers Tailored Plans, designed to meet specific healthcare needs. The pharmacy benefit structure for these plans involves different PBM processors and identification details. The following table outlines the necessary information for processing claims under Tailored Plans:
| Managed Care Organization | PBM Processor | BIN Number | PCN | Group Number(s) |
|---|---|---|---|---|
| Alliance | Navitus | 610602 | MCD | Medicaid: TPMCNCHC: TPHC |
| Partners | CVS Caremark | 025052 | MCAIDADV | RX22AC |
| Trillium | Perform Rx | 019595 | PRX10811 | N/A |
| Vaya | Navitus | 610602 | MCD | VAYARX |
Dedicated Pharmacy Help Desks are in place to support providers and beneficiaries with Tailored Plans. Effective July 1, 2024, updated contact information is available for each Tailored Plan Managed Care Organization:
| Tailored Plan Managed Care Organization | Pharmacy Help Desk Contact Information |
|---|---|
| Alliance Health | 1-855-759-9300 |
| Partners Health Management | 1-866-453-7196 |
| Trillium Health Resources | 1-866-245-4954 |
| Vaya Health | 1-800-540-6083 |
For a comprehensive overview of the Tailored Plan rollout, NC Medicaid hosted a Pharmacy Summit webinar on October 12, 2022. The recording of this informative webinar is accessible online, providing further insights into the program’s structure and implementation.
Leveraging the Preferred Drug List (PDL) for Cost-Effective Prescriptions
The NC Medicaid Preferred Drug List (PDL) is a vital tool for managing prescription drug costs while ensuring beneficiary access to necessary medications. By negotiating supplemental rebates, NC Medicaid can secure better pricing on outpatient drugs included in the PDL. The PDL operates under the authorization of the NC General Assembly Session Law 2009-451.
While prescribers are encouraged to prioritize prescribing “preferred” drugs listed on the PDL, they retain the flexibility to prescribe non-preferred drugs when clinically necessary. However, prescribing a non-preferred drug necessitates initiating a prior authorization request to ensure coverage. It is important to note that prior authorization requirements may be extended to additional drugs in the future as the PDL evolves.
For stakeholders interested in contributing to the PDL’s clinical policy, NC Medicaid provides channels for submitting proposed changes. Furthermore, the Preferred Drug List Review Panel offers a platform for engagement and oversight of the PDL’s development and maintenance. Annual reports detailing the PDL and Supplemental Rebate Program are publicly available, offering transparency and accountability in program management.
Understanding Prior Approval and Behavioral Health Clinical Edits
NC Medicaid employs prior approval processes to ensure appropriate utilization and cost-effectiveness of certain medications. These processes may involve behavioral health clinical edits, designed to promote evidence-based prescribing practices.
Resolving Behavioral Health Clinical Edits
In cases where a behavioral health clinical edit is triggered, pharmacists may utilize a Submission Clarification Code 10 (SCC 10) override. This override is appropriate when the prescribing physician provides a clinical rationale that justifies the therapy despite the edit alert. Detailed Pediatric and Adult Edits Criteria are readily accessible on the NCTracks Prior Approval Drugs and Criteria page, offering comprehensive guidance for navigating these edits.
Tamper-Resistant Prescription Pads: Ensuring Prescription Security
To combat prescription fraud and misuse, NC Medicaid mandates the use of tamper-resistant prescription pads for all written prescriptions within the fee-for-service program. These pads must incorporate at least one industry-recognized security feature from each of three critical categories:
- Features to prevent unauthorized copying of the prescription form.
- Features to prevent erasure or modification of information written by the prescriber.
- Features to prevent the use of counterfeit prescription forms.
Verifying Non-Compliant Prescriptions
In situations where a pharmacist receives a prescription that does not meet tamper-resistant pad requirements, they are permitted to contact the prescriber to verbally verify the prescription. If this verification process is undertaken, the pharmacist is required to meticulously document specific information directly on the prescription. This documentation must include:
- Initials of the pharmacy staff member who verified the prescription.
- The date on which the prescription was verified.
- The first and last name of the individual representing the prescriber who provided the verification.
Reimbursement and Fee Schedules
NC Medicaid Pharmacy Fee Schedules are regularly updated and accessible through the Fee Schedule and Covered Code site, effective from November 3, 2022. For historical fee schedules related to Diabetic Testing and CGM prior to this date, archives are available through provided links, ensuring access to past reimbursement information.
Navigating Medication Coverage Restrictions
NC Medicaid maintains Medication Coverage Restriction Lists, which outline specific limitations or guidelines for certain drug classes or medications. These lists are categorized into “Current” and “Archived” lists, allowing providers to stay informed about the most up-to-date coverage policies and access historical information as needed.
NC Select Drug List and Inpatient/Outpatient Drug Coverage
The NC Select Drug List plays a crucial role in managing drug costs within hospital settings. Drugs included on this list are “carved out” from standard inpatient DRG or outpatient RCC billing. This means that hospitals must claim these drugs separately, enabling the state to capture rebates associated with their utilization.
Specific reimbursement rules apply to drugs on the NC Select Drug List based on the setting of administration:
- Inpatient Hospital Setting: Reimbursement is provided directly to the hospital based on the ingredient cost of the NC Select Drug, calculated at the Actual Acquisition Cost net of all discounts and rebates.
- Outpatient Hospital Setting: Reimbursement is direct to the hospital at the lesser of the Actual Acquisition Cost or the Average Sales Price (ASP), net of all discounts and rebates.
- Outpatient Professional Setting: Reimbursement is direct to the provider at the lesser of the Actual Acquisition Cost or ASP, net of all discounts and rebates.
It is critical to note that drugs on the NC Select Drug List are excluded from the 340B drug pricing program. Providers are prohibited from using 340B inventory for NC Medicaid beneficiaries for drugs included on this list. For the most current information on Average Sales Price (ASP), providers are directed to the CMS website. The NC Select Drug List itself is regularly updated, with the January 2025 list being the most recent version available.
Stay Informed with Pharmacy Newsletters and Direct Contact
NC Medicaid actively disseminates important program updates and information through Pharmacy Newsletters. These newsletters are a valuable resource for staying current on policy changes, PDL updates, and other relevant program information.
For direct inquiries or further assistance, the NC Medicaid Clinical Section can be contacted via phone, fax, or email:
NC Medicaid Clinical Section
Phone: 919-855-4260
Fax: 919-715-1255
Email: [email protected]
This comprehensive overview provides essential information about the NC Medicaid Pharmacy Program, addressing key aspects relevant to beneficiaries and healthcare providers seeking to understand “Who Insures Well Care Pharmacy Program” within the context of North Carolina’s Medicaid system.
