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Pharmacy Benefit Frequently Asked Questions

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Home » Tailored Plan » Pharmacy » Pharmacy Benefit Frequently Asked Questions

Medication Coverage

The Preferred Drug List (PDL) is the list of drugs that your doctor will use first when prescribing you medicine. These drugs have been chosen for their quality and effectiveness. Your doctor can prescribe most of these medicines to you without getting prior authorization, or an “OK,” from us. The PDL is updated frequently. To see if a drug is covered under your plan, click here to view the preferred drug list.

  • An eligible Medicaid beneficiary, who receives prescribed drugs, is required to make a co-payment of $4.00 for each prescription received unless they are exempt.
  • The copays are waived for family planning medications and women who are pregnant, also those who are members of a federally recognized tribe.

There are no NC Medicaid copays for:

  • Members under age 21
  • Members who are pregnant
  • Members who get hospice care
  • Federally recognized tribal members
  • North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
  • People living in an institution who get coverage for cost of care
  • Children/youth in foster care
  • Behavioral health, intellectual/developmental (I/DD) or traumatic brain injury (TBI) services
  • Adult vaccines and vaccine administration
  • HIV antiretroviral (ARV) medications
  • HIV medications; also effective 8/1/24 no copay for nicotine replacement products or medications for opioid use disorder
  • Nicotine replacement therapies (NRT) (effective 8/1/24)
  • Naloxone (effective 8/1/24)
  • Medications for Opioid Use Disorder (MOUD) (effective 8/1/24)

An eligible Medicaid beneficiary, who receives prescribed drugs, is required to make a co-payment of $4.00 for each prescription received unless they are exempt.

NC Medicaid covers specific over-the-counter (OTC) products such as some oral antihistamines and proton pump inhibitors. To see a list of all covered drugs including brand, generic, and  OTC items, click here.

You may find a copy of the formulary/preferred drug list here.

Prior Authorization(s)

Medicaid prior authorization (PA) is when a provider must first obtain approval from the Medicaid agency or plan before a drug can be given to a member. A PA is required for non-preferred medications and many specialty pharmacy medications. Some preferred medications may also require that clinical criteria be met before being approved.

The Preferred Drug List (PDL) is the list of drugs that your doctor will use first when prescribing you medicine. These drugs have been chosen for their quality and effectiveness. Your doctor can prescribe most of these medicines to you without getting prior authorization, or an “OK,” from us. The PDL is updated frequently. To see if a drug is covered under your plan, click here to view the preferred drug list.

In certain situations, your prescriber can request a medical exception.

*These circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or undergoing a current course of treatment using a non-covered drug.

Some drugs require step therapy or a covered under a clinical coverage policy. This means that a member must try one or more other drugs before a step therapy drug is covered, these drugs treat the same condition as the drug that was prescribed to you. If you choose not to try the other drugs first, you may have to pay out of pocket for the prescribed drug. Note: To request an exception, you will need a prior authorization.

The maximum supply for all drugs is 34-day supply unless the medication meets the criteria below:

  • Up to 12 months of oral birth control medications and up to three months of prepackaged hormone replacement therapies are allowed.
  • May obtain a 90-day supply of medications if the claim is for a non-controlled, maintenance medication. Note: This is at the sole discretion of the beneficiary’s health care provider. Only one co-pay is collected and only one dispensing fee is paid for the 90-day supply.

An approved prior authorization is required. Quantity limits apply to some drugs to achieve dose improvement. Some drugs are meant to be used episodically and dispensed in quantities that support less than daily use. For quantity limitations refer to the Preferred Drug List or the specific Prior Authorization policy that can be found here.

  • Preferred drugs vs. non-preferred drugs.
  • Some preferred medications require meeting clinical criteria
  • If your drug is non-preferred, you would require a prior authorization

Brand Name versus Generic

A generic drug is a medication created to be the same as an existing approved brand-name drug in dosage form, safety, strength, route of administration, quality, and performance characteristics. Generic medicines work the same as brand-name medicines.

When a medication is first developed, the manufacturer has patent rights on the formula and/or compound. Once this patent right expires, other companies can produce generic versions of the drug that meet the same FDA requirements and regulations as the brand name drug. Most insurance companies require generic substitutions unless specifically requested by the prescriber or patient. Generic medicines work the same as brand-name medicines.

Generic medications must pass the rigorous standards established by the Federal Drug Administration (FDA). The generic product must be shown as equivalent to the brand name product. Inactive ingredients and the appearance of generic medications can vary from their brand counterparts, but these changes must be proven not to affect safety or efficacy. Generic medications are equally effective and often more affordable for patients.

Medications are generally identified by one of two names or an abbreviation. The brand name or trade name that is assigned by the manufacturer when it is introduced is the most common used by medical staff. The generic or chemical name is what will normally be printed on the label from your pharmacy since this is what they are dispensing. If you have a question related to a change in the appearance of the medication that you have been taking or an unexpected name change, always ask your dispensing pharmacist or provider before taking the medication.

Medicaid requires the member to getting a generic drug unless the brand name is preferred, or the provider specifically orders and documents the brand name drug.

If you have a prescription that is not covered, talk to your doctor or pharmacist about other options. Medicaid may cover a generic or lower cost option, a list of preferred medications can be found here.

Insurance Coverage

Please share any insurance changes with your local pharmacy staff prior to requesting refills or new prescriptions. This will help to avoid delays and any untoward expense. 

No, Partners’ plan does not provide coverage for out of network pharmacies that are not contracted with NC Medicaid.

“Specialty Drugs” means certain pharmaceuticals, biotech or biological drugs, which are used in the management of chronic or genetic disease, including but not limited to, injectable, infused, or oral medications, or products that otherwise require special handling. Many specialty drugs require prior approval for use and are dispensed by a Specialty Pharmacy.

Partners Pharmacies, Ordering & Management Information

Partners plan members are free to choose their pharmacy from among a wide range of community pharmacies that are in the pharmacy benefits manager pharmacy provider network. These can be found by using the Partners pharmacy locator

Tailored plan members can search here for a location near them to find a pharmacy that best fits their needs.

  • You may locate an in-network pharmacy using the look-up function on the Partners website
  • You may call the in-network pharmacy that you want to use to make the transfer request.
  • It is easily done if you have the prior pharmacy information including the prescription number.

Call your pharmacy or visit your Pharmacy’s website or phone app.

In the efforts of patient safety, Medicaid will not allow you to refill a medication too soon.

[To determine how soon you can fill your prescription, you must multiply the Days Supply by the Days Supply Percentage for Over Utilization (usually 75% and 85 % for benzodiazepine and opioid analgesic prescriptions)] 

If you are planning a trip and your current supply of medications will run out while you are away, discuss your needs with a member of the pharmacy staff as early as possible. In special circumstances with the appropriate documentation, vacation supplies may be given. Only one five-consecutive day occurrence each 365-day time period will be allowed for non-controlled medications. Vacation supplies are not allowed for controlled medications. 

You can ask a friend or family member to pick up your order. They will be required to sign for the medications and pay any balance due. They may be required to present their valid NC Driver’s License or other government-issued ID. Please alert the pharmacy staff ahead of time if someone new will be picking up your order to avoid confusion.

The lock-in program restricts members to a specific pharmacy and prescriber in order to obtain opioid analgesics, benzodiazepines and certain anxiolytics.

  • Beneficiary who has at least ONE of the following:
    • Benzodiazepines and certain anxiolytics: ten or more claims in two consecutive months
    • Opiates: ten or more claims in two consecutive months.
  • Receiving prescriptions for opiates and/or benzodiazepines and certain anxiolytics from four or more prescribers in two consecutive months.

A beneficiary who qualifies for the program shall be notified and locked in for two years after which time they shall be removed from the program if they no longer meet the criteria. A beneficiary who continues to meet the criteria is locked in for another two years. Once released from the lock-in program, prescription claims continue to be monitored.

The N.C. Medicaid Program will reimburse an enrolled Medicaid pharmacy for a four-day supply of a prescription dispensed to a beneficiary locked into a different pharmacy and prescriber in response to an emergent situation. The provider will be paid for the drug cost only and the beneficiary will be responsible for the appropriate copayment. One emergency occurrence is reimbursed per beneficiary during each year of the two-year lock-in period. Paid quantities for more than a four-day supply are subject to recoupment. 

Federal (DEA) and North Carolina State prescribing regulations require a standardized prescription for some drugs categorized such as CII controlled substances each time they are filled (opioid, pain medications and some ADHD therapies).

Automatic refills and automatic shipments are not allowed by Medicaid policy.

If you are unable to get your prescription filled and told that there is an error stating there is other insurance coverage, you will need to give updated insurance information or termination of your former policy to your Medicaid case worker for them to update the system for billing to go through.

Ways to update your information:

  • Contact your case worker or call your Medicaid county DSS office. DSS locations can be found at ncdhhs.gov/divisions/social-services/local-dssdirectory.
  • ePASS is North Carolina’s secure self-service website where you can apply for various benefits, view case details, renew your Medicaid and update your information without having to visit your local DSS. Sign-up today for an Enhanced ePASS account! medicaid.ncdhhs.gov/media/12236/download?attachment
  • You may also call the Medicaid Contact Center if you have any issues.
    NC Medicaid Contact Center –
    Phone: 888-245-0179
    Monday – Friday 8 a.m. – 5 p.m.
    Closed on State Holidays

Ask your pharmacy provider about medication synchronization, this is a process to get all your refills on the same cycle.

In the event of a state of emergency or disaster declared by the NC Governor, early refill override for emergency preparedness is allowed for all medications. You will still be required to pay your copay.

If the hospital pharmacy has an outpatient pharmacy and is a network provider, they can fill your prescriptions for the same copay.

You should talk to your local pharmacy provider regarding your medication questions to receive personalized support and answer questions about your medication(s). You may also speak with your care manager and provider if your questions are not answered satisfactorily.

Medication Questions

The following questions are general medication question. You should always discuss your concerns with your local pharmacy.

  • What is the name of the medication? Be sure to ask for the brand name and generic.
  • What is the medication being used for? How do I know if it is working?
  • What are the common side effects I should look for?
  • Do I need to take this medication at a certain time of the day? Should I take it with or without food? Can I take it at the same time as my other medications?
  • What if I forget to take this medication at the correct time? Do I skip the dose or take it as soon as I remember? For how long do I need to take the medication?

When dosing instructions indicate to “take with food,” it is recommended that you take the medication with a meal to avoid stomach or intestinal irritation. Other times, it is recommended that a medication be taken with a certain type of food, such as milk or cheese, to increase the amount of medicine absorbed by your body. When instructed to “take on an empty stomach,” medication should be taken either one hour before or two hours after eating. 

Once dispensed, medications cannot be resold or returned. Medications should not be flushed down the toilet or put in the garbage disposal. Call the pharmacy or visit this website for information on how to dispose of them properly to avoid harm to others. Your local pharmacy or law enforcement office may also have a drop box. 

Medications from different manufacturers, while similar, may not always look exactly alike. If there is any question whether you received the correct drug or dosage, always contact your pharmacy or provider’s office before taking the dose. 

Side effects from medications are varied. If you are experiencing general discomfort such as nausea, a rash or a headache, contact your doctor’s office. If you are experiencing chest pain, hives, a rash all over your body, or severe shortness of breath, call 911. 

What to do when you miss a dose will be different depending on the drug and the directions for its use. Always call your pharmacist to find out what to do when you miss a dose. 

While this depends on the medication, generally most prescription drugs can be left out of the refrigerator for up to 24 hours without affecting their potency. To be safe, first put the medicine back in the refrigerator, and then check with your pharmacist before taking any medication that has been left out. 

For some medicines, it doesn’t matter what time you take it. And for others, the pharmacist may recommend you take it at the same time each day. 

The U.S. Food and Drug Administration recommends never taking drugs beyond their expiration date as it is risky with many unknown variables. For example, how your drug is stored before you receive it, chemical make-up, and original manufacturing date can all affect potency of a drug. 

Most medications should be stored in a cool, dry place. The medicine cabinet in your bathroom is not an ideal location. Be sure to keep your medications and supplies out of reach of children and pets and away from other household or food items. Refrigerated medication should be kept on a clean shelf or in a clean drawer of the refrigerator. Some medications have specific storage requirements that should be listed on the bottle. Ask your pharmacist if you are not sure. 

Many foods interact negatively with certain medications. Please speak with your pharmacist for personalized information regarding your medications.

Updated: May 28, 2024

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