Effective Date: No earlier than April 15, 2026

Carolina Complete Health is providing advanced notice to its provider network of an upcoming update to utilization management (UM) requirements applicable to drugs billed under the Outpatient Hospital benefit.

Overview

In alignment with guidance issued by the North Carolina Department of Health and Human Services (NCDHHS) regarding utilization management and Food and Drug Administration (FDA) labeling, Carolina Complete Health intends to apply utilization management edits—based on FDA-approved indications and usage—to drugs billed under the Outpatient Hospital benefit.

These utilization management edits will be consistent with those currently in place under the Physician Administered Drug Program (PADP) and are intended to promote uniformity, clinical appropriateness, and regulatory compliance across sites of care.

What Is Changing

• Utilization management edits based on FDA-approved indications and usage will apply to Outpatient Hospital claims.

• These edits will mirror those currently applied under the Physician Administered Drug Program (PADP).

• The change applies only to utilization management alignment and does not introduce new clinical criteria beyond those already established under PADP.

Effective Date

• These changes will become effective for dates of service on or after April 15, 2026.

Regulatory Basis

This update is being implemented in response to NCDHHS guidance outlined in the following bulletin:

• Utilization Management for Managed Care Plans Aligned with FDA Labeling - Published December 8, 2025

Providers are encouraged to review this guidance to understand the broader policy context and expectations.

Provider Resources

To assist providers with preparation and compliance, please refer to the following resources:

• Physician Administered Drug Program (PADP) Fee Schedules and Drug Listings
  
  
• Clinical Coverage Policy 1B – Physician’s Drug Program
  

These resources outline the FDA-aligned coverage parameters, indications, and utilization management requirements that will also apply to the Outpatient Hospital benefit beginning April 15, 2026.

Providers with questions may contact Carolina Complete Health Provider Services through established channels.

Please see the Policy Updates page for recently posted policies with future effective dates. Click here to see the Policy Updates page.

Effective April 1, 2026, the following procedures will be removed from prior authorization.

The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid.

Pregnant women enrolled in NC Medicaid (regardless of Medicaid eligibility category) may not be charged co‐pays for any Medicaid-covered services. This includes all pregnant beneficiaries, regardless of Medicaid eligibility category, including but not limited to:

• MAD – Medicaid Aged, Blind, and Disabled
• MAF – Medicaid Family and Children
• MIC – Medicaid for Infants and Children
• MXP – Medicaid Expansion (Parent/Caretaker, Childless Adult groups)

This policy is not limited to individuals enrolled under the Medicaid for Pregnant Women (MPW) coverage group.

Carolina Complete Health has become aware that our pharmacy benefit manager, ESI, has issued contract notices to some of our North Carolina pharmacies. Please be assured that participation in the North Carolina Medicaid pharmacy program /network is not contingent upon executing those contract notices. CCH includes all North Carolina Medicaid-enrolled pharmacies in our network for serving our NC Medicaid members. We apologize for any concerns that the ESI notice has created for our NC pharmacies.

Wegovy and Zepbound, for indications other than weight loss, to be covered based on the indications and usage criteria published in the FDA label, pending updated clinical criteria. Click here for more from NCDHHS.