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). 

• Prescribers are encouraged to write prescriptions for “preferred” products.
• Prescribers may continue to write prescriptions for drugs not on the PDL.
• 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 requirements may be added to additional drugs in the future.
• Submit Proposed Clinical Policy Changes to the PDL
• Preferred Drug List Review Panel
• Preferred Drug List

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

Coverage Resources:

Please use the following resources for coverage details:

• Preferred Drug List (PDL)
• Clinical Coverage Policy 9A
  
• Pharmacy Clinical Coverage Criteria
• Drug Look-up Tool