The Alliance Health Tailored Plan for NC Medicaid members covers most medicines prescribed by a North Carolina Medicaid doctor. But the pharmacy program does not cover all drugs. Some drugs require prior authorization. which means it will need to be approved by the plan before the drug is covered. Some drugs may also have limits on age, dosage (amount you take), or number of pills or refills you can get. If you have other prescription drug coverage, like a Medicare Part D plan, your Medicare plan will decide these limits.
If you have questions about your pharmacy benefits, call Alliance Pharmacy Services at 855-759-9300.
How can I see if my medicine is covered by my Alliance Health Plan?
The Preferred Drug List (PDL) is a list of drugs covered by Alliance Health Plan for Medicaid-eligible members. Alliance works with the State of North Carolina to make sure medicines used to treat a variety of conditions and diseases are on the list.
To view or download a copy of the list, visit the NC Medicaid Preferred Drug List. To receive a paper copy, call Alliance Pharmacy Services at 855-759-9300 and one will be sent at no charge within 5 business days.
To see if a drug is covered by the plan, use our search tool to check the list of covered drugs. This list is called the “drug formulary.” This search tool will also show any limits for the drug. There are two ways to search the Alliance Drug Formulary:
- Start typing the name of the drug in the search box on the upper left-hand side of the page and click the name of the drug you are looking for
- Search for a drug by therapeutic class (what the drug is used for) on the left-hand side of the screen
Can I get more than a 30-day supply of medicine?
Alliance Health Tailored Plan members can get a 90-day supply of most maintenance medicines. Maintenance medicines are used to treat chronic conditions such as high blood pressure, diabetes, or high cholesterol. Members can also get a year supply of birth control. Members cannot get a longer supply of controlled substances such as medicines for pain or for attention disorders like Adderall or Ritalin.
Where can I get my medicines?
To find a pharmacy that is in the Alliance Health Pharmacy network, use the Find a Pharmacy tool. To use the tool, type in your city or ZIP code. Only the pharmacies in the Alliance Health Plan network will show.
How much will I pay for my medicines?
Medicaid members will pay a $4 copay for brand-name or generic (non-brand name) drugs including over the counter medicine. A copay is a fixed amount members pay when they get certain health care services or a prescription.
Medicaid members in these groups do not have a copay:
- Members under age 21
- People who are pregnant
- Members in hospice care
- Federally recognized American Indians or Alaska Natives
- North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
- Children in foster care
- Children with disabilities under the Family Opportunity Act
- Innovations and Traumatic Brain Injury (TBI) waiver program members
- People living in an institution who have coverage for cost of care
There is also no copay for birth control and some medical equipment such as blood sugar testing supplies, vaccines, and COVID treatments and tests.
What do I do in an emergency?
If members need to start a medicine while waiting for a prior authorization request to be approved, they can get up to a 3-day (72-hour) emergency supply. If needed, ask the pharmacist about how to get this. If a medicine is lost or stolen, contact the doctor. They will work with the pharmacy and Alliance Health to replace the medicines.
If the North Carolina Governor, FEMA, or the US President declares a state of emergency, the Alliance Health Pharmacy Benefit Manager (PBM) will waive prior approval and other coverage requirements for certain medicines. Members will be able to refill any medicines earlier than is normally allowed.
How do I get reimbursed (paid back) for my medicine if I had to pay out of pocket?
If you had to pay full price for your medicine because you did not have your Alliance insurance card and needed your medicine right away, the link below will take you to a form that you can print out and mail to our Pharmacy Benefit Manager, Navitus Health Solutions, to ask for a refund.
Please keep in mind:
- The prescription you are asking to be reimbursed for must be covered by NC Medicaid
- The reimbursement will be paid at the pharmacy contracted rate which may be less than what you paid for the medicine
- Your claims may also be subject to other limits and restrictions based on the drug’s place on the NC Medicaid Preferred Drug List
- Your claim may need prior approval from your physician before payment can be sent
