Partners Health Management covers outpatient prescription medications for members enrolled in the NC Medicaid Tailored Plan. Coverage follows North Carolina Medicaid rules and focuses on safe, effective use of medications.
This page explains:
- How pharmacy coverage works
- When approval is needed
- Where providers can find forms and tools
Partners follows the NC Medicaid Preferred Drug List (PDL) and NC Medicaid Outpatient Pharmacy Clinical Coverage Policies.
- The Preferred Drug List (PDL) shows medications that are covered first when medically appropriate.
- The PDL does not include every medication. It focuses on the most commonly prescribed drugs.
- Some medications not listed on the PDL may still be covered but may require approval.
Some medications require prior authorization. This means a provider must request approval before the medication can be covered.
Partners works with CVS Caremark, our Pharmacy Benefits Manager (PBM), to review these requests and help ensure medications are safe and appropriate.
Common Reasons Prior Authorization Is Required
- The medication is not preferred, and other options should be tried first
- The dose is outside FDA recommendations
- The medication has a high risk for misuse or abuse
- More medical information is needed
Providers can review detailed requirements on the Pharmacy Prior Authorization Criteria page.
Providers can find drug-specific prior authorization forms on the Partners Prior Authorization Forms page.
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If a form for a specific medication is not listed, use the Standard Request Form.
Prescribers can search for covered medications using the CVS Caremark Drug Look-Up Tool for Partners.
You can search by:
- Drug name
- National Drug Code (NDC), a 10-digit number that identifies the exact medication
This tool shows whether a medication is covered and whether prior authorization is required.
What Is the Physician Administered Drug Program?
The Physician Administered Drug Program (PDP) covers medications that are:
- Usually injectable drugs or biologics
- Purchased and administered by a medical professional
- Given in a doctor’s office or outpatient setting
PDP Coverage and Policies
- NC Medicaid PDP Policy
Explains statewide rules for physician-administered drugs. - PDP Catalog
Lists covered drugs and biologics, approved use and any limits or restrictions. - Partners UM Program Policy
Explains how Partners reviews and approves services and medications, including PDP requests.
PDP Off-Label Use Requests
Requests for off-label use (uses not listed in the PDP catalog) may be submitted.
- Requests must include the intended use of the medication
- Submit requests through the Provider Portal
When to Use the Manual Authorization Request Form
The Manual Authorization Request Form should only be used in limited situations, including:
- The ProAuth/TruCare system is unavailable for an extended time (typically 4 hours or more)
- System outages will be posted on the Partners website
- The provider is out-of-network or non-participating, and:
- Specialty care is not available in the network, or
- The member is outside the Partners service area during a crisis, or
- The member lives outside the Partners region but still has Medicaid from a Partners county
- A service is requested that is not listed in the Partners Benefit Plan and is not available in ProAuth/TruCare
- Example: an EPSDT request for a service not normally covered under the plan