Outpatient Pharmacy Benefit

What is the Outpatient Pharmacy Benefit?

The outpatient pharmacy benefit includes a comprehensive list of prescription drugs, plus certain select OTC products. The outpatient pharmacy benefit also includes the Home Infusion Therapy (HIT) program that covers self-administered infusion therapy, including IV chemotherapy and IV antibiotics.

Which drugs are covered?

The Preferred Drug List (PDL) allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. The PDL was authorized by the NC General Assembly Session Law 2009-451, Sections 10.66(a)-(d). 

How to obtain medication pre-authorization?

If a prescriber deems that the patient’s clinical status necessitates therapy with a non-preferred drug, the prescriber will be responsible for initiating a prior authorization request.

Prior Authorization Forms

Three ways providers may submit Outpatient Pharmacy Requests:

Disclaimer: For durable medical equipment, medical services, procedures, and nursing visits (including home infusion nursing visits). Please refer to the Medicaid Pre-Auth Tool for more information.