Pharmacy
Carolina Complete Health covers certain prescription drugs and over-the-counter drugs when prescribed by an in-network provider. The pharmacy program does not cover all drugs. Some drugs require prior authorization and may have limitations on age, dosage or maximum quantities.
Outpatient Pharmacy:
Retail / Specialty / Home Infusion
Physician Administered
Drug Program (PDP)
Over-the-Counter:
Medications and Products
Immunizing Pharmacist Enrollment Information
NC Medicaid allows immunizing pharmacists to enroll as providers using the Ordering, Prescribing, and Referring (OPR) Lite application starting on Jan. 8, 2024.
Enrollment will support utilization of the NC Medical Board and Board of Pharmacy statewide protocols which authorize immunizing pharmacists to dispense, deliver or administer the following:
- Self-Administered Hormonal
- Contraceptive Protocol
- Nicotine Replacement Therapy Protocol
- Prenatal Vitamins Protocol
- Post-Exposure Prophylaxis (PEP) for HIV Protocol
- Glucagon Protocol
Read the Medicaid Bulletin for more information and view our Pharmacist Guide (PDF) for a checklist reviewing the steps from enrollment to getting claims paid.
Recent Updates
- Opioid Analgesicso
- Adding Seglentis to short acting list
- Monoclonal Antibodyo
- Adding IgE-mediated food allergy criteria for Xolair
On April 1, 2025, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html
On January 1, 2025, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html
Express Scripts Transition: Frequently Asked Questions
This FAQ provides additional information on the migration of our Pharmacy Benefit Manager (PBM) services from CVS® to Express Scripts®, effective January 1, 2024.
Who is Express Scripts?
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
What is the rationale for changing PBM vendors?
Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.
What PBM services will Express Scripts be providing?
Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.
How will this PBM transition impact our members?
There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.
Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.
Is Amazon part of the Express Scripts Network?
Yes, Amazon is part of the Express Scripts network.
Can members still use CVS Caremark for their mail orders?
No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.
Do members have a choice besides Express Scripts for mail order services?
Members have a choice to use other pharmacies that offer home delivery but Express Scripts Pharmacy is the preferred mail order pharmacy for our health plan.
Are we communicating this mail order change to members?
Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.
How will members get started with mail order at Express Scripts?
For existing mail order users:
- Most open prescription refills will be automatically transferred to Express Scripts
- Refills for controlled drugs, such as Alprazolam, Clonazepam, Pregabalin, Tramadol, Zolpidem, etc., will not automatically transfer to Express Scripts Pharmacy; members must request a new prescription from their provider
For new mail order prescriptions on or after January 1, 2024, members may do one of the following:
- Ask their provider to electronically submit or fax a new prescription to Express Scripts Pharmacy, as listed on their medical ID cards
- Visit express-scripts.com/rx to register or sign in, then follow the guided steps to request a prescription
- Call Express Scripts Pharmacy, who will contact their provider for a new prescription to be filled via mail order
- Mail a Home Delivery Order Form (available at express-scripts.com/rx) directly to Express Scripts Pharmacy
Does Express Scripts offer a mail order app?
Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.
2024
October 1, 2024: Preferred Drug List (PDL) Updates
On October 1, 2024, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html
October 1, 2024 - Prefered Drug List (PDL) Updates (PDF)
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July 1, 2024: Preferred Drug List (PDL) Updates
On July 1, 2024, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html.
July 1, 2024 - Prefered Drug List (PDL) Updates (PDF)
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April 1, 2024: Preferred Drug List (PDL) Updates
On April 1, 2024, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html.
April 1, 2024 - Prefered Drug List (PDL) Updates (PDF)
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February 19, 2024: Recent Updates to Outpatient Pharmacy Clinical Coverage Criteria and Revisions to Authorization Request Forms
Beginning March 1, 2024, the following updates will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms:
- Continuous Glucose Monitoring (CGM)
- Removed the beneficiary requires two (2) or more insulin injections daily and the beneficiary’s insulin treatment regimen requires frequent adjustment based on standard BGM or non-therapeutic CGM testing.
- Added coverage for gestational diabetes
- Opioid Dependence Therapy Agents
- Add Lucemyra
- Sedative Hypnotics
- Add Quviviq
- Remove brand name Intermezzo, remove NC Health Choice
- Triptans
- Add Rizafilm
- Remove NC Health Choice
- Cystic Fibrosis
- Age for Trikafta changed to 2 and up and added strengths
- Age for Kalydeco changed to 1 month and older
- Age for Orkambi changed from 2 years to 1 year or greater
- Add Kalydeco 13.4mg granules and Kalydeco 5.8mg granules
- Add Orkambi 75-94mg granules
- Hereditary angioedema (HAE)
- New criteria
- Camzyos
- New criteria
- GLP-1 Receptor Agonists and Combinations
- New policy
- Hematinics
- Add diagnosis of Sickle Cell Disease with Hemoglobin less than or equal to 10 (for Sickle Cell) for initial and Hemoglobin less than or equal to 11 (for Sickle Cell) continuation.
- Opioid Analgesics
- Add Seglentis, tramadol solution,
- Add Seglentis QL
- Remove obsolete and/or non-rebateable products
- Update link to new CDC guidelines
- Add Prolate
- SGLT2 Inhibitors and Combinations
- New criteria
- Topical Local Anesthetics
- Separated out criteria for preferred vs non-preferred agents
- Added step through preferred lidocaine patch for approval of non-preferred agents
- Added, “or beneficiary has a documented clinical reason that these products cannot be tried.”
- Remove NC Health Choice
- Vivjoa
- New criteria
- Vowst
- New criteria
- Zolgensma
- Addition of INR testing to baseline testing due to blackbox warning regarding acute liver failure
- Removed NC Health Choice language
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January 1, 2024: Express Scripts Transition Frequently Asked Questions
Express Scripts Transition: Frequently Asked Questions
This FAQ provides additional information on the migration of our Pharmacy Benefit Manager (PBM) services from CVS® to Express Scripts®, effective January 1, 2024.
Who is Express Scripts?
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
What is the rationale for changing PBM vendors?
Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.
What PBM services will Express Scripts be providing?
Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.
How will this PBM transition impact our members?
There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.
Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.
Is Amazon part of the Express Scripts Network?
Yes, Amazon is part of the Express Scripts network.
Can members still use CVS Caremark for their mail orders?
No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.
Do members have a choice besides Express Scripts for mail order services?
Members have a choice to use other pharmacies that offer home delivery but Express Scripts Pharmacy is the preferred mail order pharmacy for our health plan.
Are we communicating this mail order change to members?
Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.
How will members get started with mail order at Express Scripts?
For existing mail order users:
- Most open prescription refills will be automatically transferred to Express Scripts
- Refills for controlled drugs, such as Alprazolam, Clonazepam, Pregabalin, Tramadol, Zolpidem, etc., will not automatically transfer to Express Scripts Pharmacy; members must request a new prescription from their provider
For new mail order prescriptions on or after January 1, 2024, members may do one of the following:
- Ask their provider to electronically submit or fax a new prescription to Express Scripts Pharmacy, as listed on their medical ID cards
- Visit express-scripts.com/rx to register or sign in, then follow the guided steps to request a prescription
- Call Express Scripts Pharmacy, who will contact their provider for a new prescription to be filled via mail order
- Mail a Home Delivery Order Form (available at express-scripts.com/rx) directly to Express Scripts Pharmacy
Does Express Scripts offer a mail order app?
Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.
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2023
October 1, 2023: Preferred Drug List (PDL) Updates
On October 1, 2023, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html.
October 1, 2023 - Prefered Drug List (PDL) Updates
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April 1, 2023: Preferred Drug List (PDL) Updates
On April 1, 2023, the attached PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found on the Outpatient Pharmacy Benefits webpage.
April 1, 2023 - Prefered Drug List (PDL) Updates
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2022
April 27, 2022: Recent Update to Outpatient Pharmacy Prior Authorization Request Fax Number
Beginning April 27, 2022, providers submitting outpatient pharmacy prior authorization requests will fax requests to our new fax number at (833) 404-2393, which is listed on the individual request forms. This will include retail, specialty and home infusion prior authorization requests. As a reminder, these requests may also be submitted online at https://www.covermymeds.com/main/prior-authorization-forms/External Link
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February 1, 2022: Recent Updates to Outpatient Pharmacy Clinical Coverage Criteria and Revisions to Prior Authorization Request Forms
Beginning February 1, 2022, the following changes will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms:
- Cystic Fibrosis
- Minimum age for Trikafta changed from 12 years to 6 years, or greater. Updated criteria and form.
- Hepatitis C
- Clarified duration of therapy for Mavyret for treatment experienced genotype 1 & 3 patients, includes patients with liver and kidney transplant. Minimum age for Mavyret changed from 12 to 3 years of age; minimum weight requirement removed; added Mavyret pellet packs. Updated criteria and forms for Mavyret.
- Minimum age for Epclusa changed from 6 to 3 years of age; minimum weight requirement removed; added Epclusa pellet packs. Updated criteria and forms for Epclusa and generic Epclusa, Sofosbuvir-Velpatasvir.
- Opioid Analgesics
- Added generic Hysingla ER. Updated criteria with no change to form.
- PCSK9 Inhibitors
- Added Homozygous Familial Hypercholesterolemia (HoFH) for Praluent. Updated criteria and form.
- Zolgensma
- Added exemption from providing (CHOP-INTEND) score or HINE score for infants initiating treatment based on Newborn Screening results indicating baby has SMA. Updated criteria and form.