Effective March 13, 2020: Recommendations for social distancing in response to the COVID-19 present situations where Medicaid and Health Choice beneficiaries may benefit from an early refill or expanded quantity (up to 90 days’ supply) of their prescription medications. NC Medicaid policy allows a 90-day supply to be filled when the prescription is either written for a 90-day supply or has enough refills remaining to fill for up to 90 days.
- Note that these edit changes do not apply to controlled substances. Additionally, providers are encouraged to follow all applicable state and federal laws and regulations for controlled substances.
- If necessary, up to a 14-day emergency supply can be billed for any pharmacy claim requiring prior approval when no active prior approval is showing in NCTracks.
- For beneficiaries in the Pharmacy Lock-in Program needing emergency supplies of Lock-In program-related medications, up to a 14-day emergency supply can be billed. This override is only valid once per beneficiary per year. Beneficiaries and providers may also contact the NCTracks call center to change either the preferred Lock-In pharmacy or preferred Lock-In prescriber on an emergency basis.
- Copay requirements are still applicable to these pharmacy claims.
This information is an excerpt from Pharmacy: Temporary Flexibilities Effective March 13, 2020, in SPECIAL BULLETIN COVID-19 #2: General Guidance and Policy Modification.
As of April 6, 2020, NC Medicaid and NC Health Choice beneficiaries may fill prescriptions for up to 90 days supply for:
- Schedule 2 medications typically prescribed for Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (i.e. Adderall XR, amphetamine combo, methylphenidate, Vyvanse, etc.)
- Medications prescribed for Opioid Use Disorder Medication Assisted Treatment and paid for via the point of sale outpatient pharmacy program (i.e. Suboxone, etc.)
- Medical providers are encouraged to write prescriptions for up to 90 days supply of these medications where clinically appropriate so beneficiaries may utilize this important benefit
- Please be aware that these edit changes do not apply to any other controlled substances. Additionally, we encourage providers to follow all applicable state and federal laws and regulations for controlled substances.
- Refer to the Special Pharmacy Newsletter dated March 13, 2020, for a listing of other flexibilities initiated, including allowing up to 90 days supply of most non-controlled substance medications
Co-pay requirements are still applicable to these pharmacy claims.
This information is excerpted: North Carolina Special Medicaid Pharmacy Newsletter Number 315 April 2020: Pharmacy Claims Flexibility Available to Prevent Spread of Coronavirus Disease (COVID-19); and COVID-19 NC Medicaid Outpatient Pharmacy Program Outpatient Pharmacy Policy Pharmacy Flexibilities Summary Page from CCNC.
FDA COVID-19 guidance for prescribers and dispensers for REMs medications, 3/22/2020
The U.S. Food and Drug Administration issued a new guidance to sponsors and healthcare providers regarding certain Risk Evaluation and Mitigation Strategy (REMS)-required testing during this time. Read the full FDA news release.
FDA Safety Alert: Gabapentinoids and Serious Breathing Problems (12/19/2019)
NC Medicaid Updates
Visit NC Tracks Pharmacy Services Announcements to see the latest pharmacy-related communications from NC Medicaid.
Links to PDL are on the upper right corner. Links to PA Criteria and Forms are on the right side of the page.
- A+KIDS (Off Label Antipsychotic Safety Clinical Coverage Policy No: 9D Monitoring In Beneficiaries Through Age 17)
- ASAP (Off Label Antipsychotic Safety Clinical Coverage Policy No: 9E Monitoring In Beneficiaries 18 and Older)
- Antipsychotic Prescribing – Key Tips for NC Medicaid (Jan 2016)
- Opioid Dependence Therapy Agents
- New Check for Opioid Drug Interaction (October 2018) NC Medicaid has an edit in NCTracks pharmacy claim processing to provide a further check for opioid and benzodiazepine interactions. This allows identification of a drug interaction for an opioid analgesic or benzodiazepine when it is determined that there is overlapping use of a different opioid or benzodiazepine within the previous 68 days.
- Pharmacy claims failing the check will deny. This denial can be overridden by the dispensing pharmacist after consulting with the prescriber(s) to determine the clinical need for the concurrent use of the opioid and the benzodiazepine.
- For additional information on the NC Medicaid commitment to curtail opioid abuse, refer to the “Opioid Criteria Educational Materials” on the Pharmacy Services webpage of the NCTracks provider portal.
- There is a maximum daily dose for opioid dependence treatment medications per the table below. The dispensing pharmacist may override the edit at point-of-sale after consulting the prescriber to determine the clinical need for the higher dose. Documentation is to be made in the NCPDP pharmacy system or on the original prescription. The pharmacist can override this when the prescriber provides a clinical rationale for the therapy issue alerted by the edit. A prescriber may proactively document the clinical rationale with the issuance of the prescription. The concise documentation may provide information about the patient’s situation, history, therapy goals, and outcome. Documentation solely of a diagnosis code is not a legitimate justification. The adequacy of proactive documentation is the professional judgment of the pharmacist. Questions can be directed to the CSRA Call Center at (866) 246-8505.
|Medication||Maximum Dose Edit||Override Available|
|Suboxone and buprenorphine/naxalone||16mg/day||up to 24mg/day|
|Zubsolv||11.4mg/day||up to 17.1mg/day|
|Bunavail||8.4mg/day||up to 12.6mg/day|
|Buprenorphine single ingredient product||16mg/day||up to 24mg/day|
- Opioid Dependence Therapy Agents Coverage Changes (November 2017)
- STOP Act Information (January 2018)
- Sublocade Added to Preferred Drug List (March 2018)
- Vivitrol (November 2016)
CPESN Pharmacy Locator Tool
The Community Pharmacy Enhanced Services Network (CPESN) allows users to search for NC CPESN pharmacies either by location or by the type of enhanced service(s) needed plus location. The tool is intended for use by care managers, providers, hospital discharge planners, and others to locate a CPESN pharmacy in their community to support patients with complex care needs. The Community Pharmacy Enhanced Services Network (CPESN), an open network of over 200 North Carolina pharmacies committed to broadening the availability of medication management resources to our state’s highest-needs population. The goal of the CPESN is to improve quality of care and patient outcomes related to medication use, enhance patients’ overall health trajectory and reduce the total cost of care. Please share this information within your organization. If there are questions about any of this information, please contact Dr. Vera Reinstein, Alliance Pharmacist by email or at (919) 651-8640.
Lock Your Meds NC
Information on how to safely secure and dispose of prescription drugs to keep them out of the wrong hands. The website also helps people identify warning signs of potential drug abuse and lists available resources to get help.
- NC Naloxone Distribution Kit
- Naloxone Resource Guide for Alliance Health
- NC DHHS site
LAI Antipsychotic Injection Administration Resources
If your office does not give LAIAs, to find a treatment location that can administer LAIAs, the CPESN locator Tool described above can locate pharmacies offering injection services to patients. Alternatively, for aripiprazole long-acting injections (Abilify only, not Aristada injection), Local Care Centers (LCCs) are alternate treatment locations that administer ABILIFY MAINTENA and may be more convenient for patients. LCCs may be retail pharmacies, urgent care clinics, dialysis centers, or infusion centers in your neighborhood. For inpatient providers, LCCs help bridge the gap between discharge and the next injection. For outpatient providers, LCCs provide more options for patients by offering convenient locations and flexible times. Visit here for more information and to find a LCC in your area. An LCC may also to be willing to administer other LAIAs besides just Abilify Maintena.
Perinatal Substance Abuse Project
Perinatal Substance Use Project at the Alcohol/Drug Council of North Carolina provides resources on substance use services for North Carolina women who are pregnant or parenting and using substances. Judith Johnson-Hostler at (800) 688-4232 or email her.
Medication Patient Assistance Programs
- Local County Assistance Programs
Cumberland County (CCMAP) Formulary
Durham County Indigent Pharmacy Program Formulary and MAP Formulary
Wake County Pharmacy Support including the Formulary, Wake County labs, and Clozapine Patient Assistance Guide.
- Medication Assistance Program (MAP)
Non-profit organization, listed by county, that provides access to free prescription drugs for uninsured, low-income individuals. Prescription drugs are available through participating pharmaceutical manufacturers.
- Medicine Assistance Tool
Free online program that connects individuals to patient assistance programs and to free and low-cost clinics in their area.
- Patient Advocacy Foundation (PAF) Co-Pay Relief Program (CPF)
Provides direct financial assistance to qualified individuals, assisting them with prescription drug co-payments, coinsurances and deductibles. Individual must have insurance and coverage for the medication for which they are seeking financial assistance and their income must fall below the income guidelines, either 300% or 400% or less of the FPL. CPR call counselors work directly with the individual as well as with the provider of care to obtain necessary medical, insurance and income information to advance the application in an expeditious manner. Upon approval, payments are made to the doctor, pharmacy, and individual directly.
- NC Med Assist
Non-profit pharmacy program for North Carolina residents that provides FREE access to lifesaving prescription medications, patient support, advocacy and related services to poor, vulnerable, and uninsured North Carolina residents. The pharmacy mails the prescriptions to North Carolina residents who live outside of Mecklenburg County.
- Rx Outreach
Non-profit mail order pharmacy in St Louis that ships directly to individuals’ homes. It is available to qualifying individuals and families. Patients can be on Medicaid, Medicare or other health insurance and still receive medications from Rx Outreach. There are no enrollment or membership fees.
Pharmacy Discount Programs
- Blink Health
For-profit company that offers a free app that finds the cheapest price for a drug and locks it in for individuals who can then pay on-line and fill their prescriptions at one of 60,000 pharmacies in the United States.
A huge consumer group buying service for the uninsured and underinsured. The discounts and savings on medications are provided voluntarily by the more than 61,000 participating pharmacies that have agreed to provide prices similar to what they give large insurance companies and employers.
- Good Rx
For-profit company that collects and compares prices and then offers consumers a coupon to get the best rate. The company has information on every FDA approved medication at more than 70,000 US pharmacies (mostly chains). Once the individual finds the best price at a local pharmacy, they can either print a coupon or show it on their smart phone.
- NCMS Discount Prescription Drug Card
Touts savings of up to 75% (discounts average roughly 30%) at more than 68,000 national and regional pharmacies. This card can be used as your primary plan and/or it can be used on prescriptions not covered by your insurance plan.
Non-profit clearinghouse that provides information on all medical needs, including medications. It collects data on patient assistance programs, drug coupons and rebates, and offers its own drug discount card.
- Major pharmacy chains’ prescription discount plans (independent pharmacies may match these prices)
Preferred Drug List (PDL) Navigation Tips
Each year North Carolina Medicaid publishes their Preferred Drug List (PDL). Those agents listed as preferred do not require prior authorization unless clinical criteria apply. Those agents that are non-preferred will require a non-preferred drug request (prior authorization). If you have a patient who is stable on a non-preferred product, and want them to continue on it, you will need to fill out a standard drug request prior authorization form.
Access the NCTracks Pharmacy Services.
The following types of information are listed in red font within the PDL document:
- Quantity limits: for example, 102 DAYS SUPPLY PER 12 MONTHS for antihistamine/decongestant combinations
- Step therapy requirements: for example, REQUIRES TRIAL AND FAILURE OF ACE INHIBITOR
- Prior authorization criteria: “Clinical criteria apply” indicates drugs or drug classes with specific prior authorization criteria
- Exemptions: for example, patients with seizure disorder are exempt from PA requirements for second generation anticonvulsants
72-Hour Emergency Supply
Reminder: Pharmacies may dispense an emergency 72-hour supply if a beneficiary is awaiting prior authorization.
Prior Authorization Requests
Requests may be submitted via fax, phone or through the NCTracks Web Portal using your NCID and password (log in here)
NCTracks Pharmacy Call Center
Phone: (866) 246-8505
Fax: (855) 710-1969
Hours of operation:
Monday through Friday, 7:00am-11:00pm, Saturday and Sunday, 7:00am-6:00pm
All NC residents can access free evidence-based tobacco treatment services through QuitlineNC. These services include telephone treatment sessions with highly trained Quit Coaches, web coaching, texting, and free nicotine replacement therapy (NRT). View these documents for the Quitline NC Behavioral Health Program program details.