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Pharmacy Guidance for Providers

This page contains a variety of helpful information to assist providers in ensuring that our members get the most out of their pharmacy benefits.

Alliance Health will not be providing outpatient pharmacy claims processing, outpatient pharmacy prior authorization, and pharmacy lock-in programs for NC Medicaid Tailored Plan beneficiaries until April 1, 2023. Therefore, some of the pharmacy benefits information and links found on this page will not be applicable or active until that time.

Medicaid Direct, via the NCTracks system, will continue processing outpatient pharmacy claims for Tailored Plan members until April 1, 2023. Providers and pharmacies with questions about outpatient pharmacy claims or prior authorization requests should contact NCTracks (GDIT) at 800-688-6696 from now until March 31, 2023.

All medical claims, including reimbursement for products covered under the Physician Administered Drug Program, should be submitted to Alliance Health beginning December 1, 2022. For information on how to submit a medical claim, please refer to the Alliance Health claims submission page.

Alliance Health is committed to working with providers to improve members’ health and well-being by delivering physical, behavioral, emotional and social services while respecting the treatment choices of our members. The following information will help your patients get the most out of their pharmacy benefits.

Preferred Drug List (PDL)

Pharmacy Prior Authorizations

Prior authorization is required for certain drugs prescribed to Alliance Health Plan members.  Navitus, our contracted Pharmacy Benefit Manager, reviews pharmacy prior authorizations to make sure prescribed medications are safe and appropriate.

Reasons that a medication may require preauthorization:

  • Medication is not preferred and other alternatives are recommended
  • Dose is outside FDA recommendations
  • Medication is a high risk for abuse or misuse
  • Medication requires additional information.

See Prior Approval Drugs and Criteria for details.

How to Submit an Outpatient Pharmacy Prior Authorization (PA) Request

Prescribers have three options:

  • Log into the Provider Portal and submit a request electronically
  • Fax completed Prior Authorization Forms to 855-668-8553
  • Call the Pharmacy and Provider Services Line at 855-759-9300 between the hours of 7 a.m. and 6 p.m. EST, Monday through Saturday

Alliance Member and Recipient Services is also available to respond to member questions and concerns about pharmacy benefits at (800) 510-9132 Monday through Saturday, 7 a.m. to 6 p.m. EST.

Emergency Supply

If a member needs to begin therapy with a medication before the prior authorization request is approved, pharmacies are authorized to dispense up to a 72-hour emergency supply.

If a state of emergency or disaster is declared by the NC Governor, FEMA or the US President, the Alliance Health Pharmacy Benefit Manager will enact the following protocol at the direction of the NC Department of Health and Human Services (NCDHHS) to ensure you can get life-saving medications:

  • Alliance will waive prior approval and other coverage requirements for certain non-preferred medications and members will be able to refill medications earlier than is normally allowed. This early refill exception applies to all medications. Member copayment requirements will not be waived during an emergency or disaster.
  • Alliance will allow members to obtain up to a 90-day supply of most medications if requested and available a the time of refill.
This page was last reviewed for accuracy on 02/06/2022