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Pharmacy

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.

Carolina Complete Health covers most prescription medications. Some prescriptions require prior authorization and may have limitations based on age or the amount of medicine prescribed. Carolina Complete Health also covers certain over-the-counter medications with a prescription from a Carolina Complete Health provider.

What Pharmacy Benefits are covered?

Carolina Complete Health covers certain prescription drugs and over-the-counter drugs when prescribed by a Carolina Complete Health provider. The pharmacy program does not cover all drugs. Some drugs require prior authorization and may have limitations on age, dosage or maximum quantities.

Which Drugs are covered?

The Preferred Drug List (PDL) is a list of drugs covered by Carolina Complete Health. Carolina Complete Health works with the State of North Carolina to ensure that medications used to treat a variety of conditions and diseases are covered. The Preferred Drug List includes drugs you receive at retail pharmacies. Carolina Complete Health adheres to the NC Medicaid Preferred Drug List.

  • 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

Pharmacy Clinical Coverage Criteria

Pharmacy/Medication Pre-Authorization

  • The Physician Administered Drug Program (PDP) covers certain primarily injectable drugs or biologic agents that are purchased and administered by a medical professional in office or in an outpatient clinic setting.
  • The PDP catalog has a comprehensive list of covered drugs or biologic agents, with approved indications and restrictions.
  • PDP requests can be submitted for off-label use. Such requests should contain information on the intended use of the drug.

For the Physican Administered Drug Program (PDP), please click here.

How to Submit PDP Requests

Providers may submit PDP off-label use medication requests under the service type of “BIOPHARMACY” through the Provider Portal.

Details

  • The Home Infusion Therapy (HIT) program covers self-administered infusion therapy, including IV chemotherapy and IV antibiotics through the outpatient pharmacy benefit.
  • Please use the formulary search tool OR refer to the Preferred Drug List (PDL) for coverage details.
  • Please see below for specific drug prior authorization request forms. In the absence of a specific form please use the Standard Request Form for prior authorization requests.

Disclaimer

For medical services, procedures and durable medical equipment please refer to the Medicaid Pre-Auth Tool.

How to Submit Home Infusion Therapy (HIT) Medication Requests

Providers may submit Home Infusion Therapy (HIT) requests can be submitted in 3 ways: 
  1. Cover My Meds Portal
  2. Fax​
    1-866-399-0929
  3. PA Prescriber Help Desk (EPS)
    1-833-585-4309

Details

Disclaimer

For medical services, procedures and durable medical equipment please refer to the Medicaid Pre-Auth Tool.

How to Submit Outpatient Pharmacy Requests

Providers may submit HIT requests in 3 ways: 
  1. Cover My Meds Portal
  2. Fax​
    1-866-399-0929
  3. PA Prescriber Help Desk (EPS)
    1-833-585-4309

Preferred Drug List

Pharmacy Prior authorizations can be submitted in 3 ways: 

  1. Cover My Meds Portal
  2. Fax​
    1-866-399-0929
  3. PA Prescriber Help Desk (EPS)
    1-833-585-4309

Prior Approval Request Forms

Page Last Updated: 04/24/2024