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.