Medicare and Medicaid Information for North Carolina Pharmacists

Check here regularly for the latest information regarding Medicare and Medicaid.



NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE STATEMENT ON DISPENSING OPIOIDS TO MEDICAID BENEFICIARIES WHEN THE PRESCRIBER HAS NOT OBTAINED A REQUIRED PRIOR AUTHORIZATION.  Due to decades of increased prescribing of opioids, North Carolina is experiencing an opioid epidemic. NC Medicaid worked closely with prescribing physicians and pharmacists to develop the best approach to reduce the oversupply of prescription opioids available for diversion and misuse, promote safe opioid prescribing for patients, and encourage alternative pain management, while minimizing administrative requirements as much as possible. Modifying clinical coverage criteria to promote safe opioid prescribing was identified as an essential and significant step to realize the vision of the North Carolina Opioid Action Plan to reduce opioid deaths by 20 percent by 2021.

On Aug. 27, 2017, NC Medicaid began requiring prior approval (PA) for opioid prescribed analgesic doses that exceed 120 mg of morphine equivalents per day; are greater than a 14-day supply of any opioid; or are non-preferred opioid products on the NC Medicaid Preferred Drug List (PDL). Effective Jan. 2, 2018, the clinical coverage criteria for opioid analgesics was updated to comply with the quantity limits mandated by the Strengthen Opioid Misuse Prevention (STOP) Act, S.L. 2017-74. Prior approval is now required for short-acting opioids for greater than a five-day supply for acute pain and seven-day supply for post-operative acute pain. Prior approval is also required for long-acting opioids for greater than a seven-day supply. Beneficiaries with diagnosis of pain secondary to cancer will continue to be exempt from prior approval requirements.

Soon after implementation of these changes, NC Medicaid began receiving reports from pharmacists that some prescribers were prescribing a 30-day supply of an opioid, but refusing to request prior authorization (PA). This situation has resulted in Medicaid beneficiaries asking the pharmacist to partial fill the opioid prescription with concurrent allowed day supplies or asking to pay cash for the quantity exceeding the quantity paid for by Medicaid.

NC Medicaid is aware that pharmacists may provide a partial fill of a Schedule II controlled substance prescription when the prescription is written and filled in compliance with federal and state law and the partial fill is requested by the patient or the prescriber. However, the intent of our clinical coverage criteria changes were to encourage prescribers to evaluate the medical necessity of an opioid to treat a patient’s chronic pain not related to cancer or end of life care and, when appropriate, request PA for those patients.

NC Medicaid has no authority to prohibit beneficiaries from paying cash for any of their medications and the intent of our clinical coverage criteria changes were not intended to require Medicaid beneficiaries to pay out of pocket for opioids determined to be medically necessary and appropriate to treat their chronic pain. Understanding the intent of our changes to opioid clinical coverage criteria, NC Medicaid encourages pharmacists to use their professional judgement when a Medicaid beneficiary requests to pay cash for their prescribed opioids. Prescribers and pharmacists are also reminded that the Controlled Substance Reporting System (CSRS) collects data on all cash transactions for controlled substances, and this data can be reported to the medical and pharmacy boards for their review and investigation of any suspected inappropriate prescribing or dispensing of controlled substances.

NC Medicaid also encourages pharmacists to contact prescribers who refuse to request PA for an opioid prescription that exceeds criteria to determine the medical necessity for the prescribed opioid and remind the prescriber of the PA requirement. While a pharmacist should not consider failure to follow NC Medicaid PA protocols, by itself, suspicious or inappropriate prescribing, the NC Medical Board continues to encourage pharmacists to report any prescriber they reasonably believe is engaged in suspicious or inappropriate prescribing of any medication.

NC Medicaid appreciates the partnership of all medical and pharmacy providers to combat the opioid crisis in North Carolina and to keep our fellow North Carolinians safe. We realize the impact of these changes to all providers and beneficiaries, but equally realize that these changes were necessary to address this crisis and to promote appropriate opioid prescribing.



MAY 11, 2015 - From NCTracks / NC Division of Medical Assistance

Attention:  Pharmacists and Prescribers

N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes

Effective June 5, 2015, the N.C. Division of Medical Assistance (DMA) will make changes to the N.C. Medicaid and N.C. Health Choice (NCHC) Preferred Drug List (PDL) showing preferred and non-preferred oral antipsychotic medications. The use of a non-preferred anti-psychotic medication will require the trial and failure of only one (1) preferred anti-psychotic medication or a prior authorization (PA).




INFORMATION FROM NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE REGARDING WAIVER OF CO-PAYS FOR MEDICAID RECIPIENTS.  Board of Pharmacy staff often receive questions about whether and to what extent state and federal law permit a pharmacy to waive co-payments for Medicaid recipients.  Board staff refer such questions (and others concerning North Carolina Medicaid issues) to staff of the North Carolina Division of Medical Assistance (“NCDMA”), which administers the North Carolina Medicaid program.  Pharmacists and pharmacies should note, however, that the NCDMA published an article in the October 2013 edition of the Medicaid Pharmacy Newsletter on the subject of waiving of Medicaid co-payments to provide additional information in light of a new state law that went into effect on October 1, 2013.  North Carolina Session Law 2013-145 ( prohibits waiving of Medicaid co-payments as a regular business practice.  NCDMA’s October newsletter, which contains the article at pages 5-7, may be found here. Pharmacists or pharmacies with additional questions should contact NCDMA for further information.

MONDAY, JUNE 4, 2012

NORTH CAROLINA MEDICAID IMPLEMENTS “BRANDS” PROGRAM.  North Carolina pharmacists should review information about North Carolina Medicaid’s newly implemented “BRANDS” program, which sets new policies concerning the dispensing of name-brand medications to Medicaid beneficiaries:  Click here for more information. Pharmacists with questions about the program should contact the North Carolina Division of Medical Assistance.

MONDAY, APRIL 9, 2012 - Update from the NC Department of Health & Human Services Division of Medical Assistance regarding tamper-resistant prescription pads (click here to read).


SUBSTITUTION OF ROCHE DIABETES SUPPLIES FOR PRODIGY DIABETES SUPPLIES FOR NORTH CAROLINA MEDICAID PATIENTS.  The North Carolina Division of Medical Assistance has designated Roche as its supplier of diabetes supplies for North Carolina Medicaid patients.  Pharmacists have inquired whether a switch from Prodigy products (the prior DMA-approved provider) to Roche products requires a new prescription.  Board staff deems substitution permissible without a new prescription.  Board staff strongly advises pharmacists, however, to counsel patients receiving Roche supplies for the first time to reduce confusion, ensure proper use, and promote good health outcomes. 


CMS ENDS CONTRACT WITH FOX INSURANCE COMPANY DRUG PLAN. In follow-up news concerning problems with Fox Insurance Company’s Medicare Part D Plan, CMS has decided to end its contract with Fox. This decision could impact the 123,000 enrollees. This press release provides more information concerning re-enrollment of patients previously covered by the Fox plan:


Suspension of Fox Insurance’s Medicare Part D Plan. Medicare has suspended Fox Insurance’s Medicare Part D plan. This action may impact several thousand North Carolinians. This press release from the North Carolina Department of Insurance details how the SHIIP program may be able to help some of those affected:


GETTING READY FOR MEDICARE D IN 2010: Information for Pharmacists on Medicare D, provided by Senior PharmAssist & The NC Seniors’ Health Insurance Information Program (SHIIP).


North Carolina Seniors’ Health Insurance Information Program (SHIIP) and Senior PharmAssist Issue Guidance to NC Pharmacists on Medicare Part D Open Enrollment Period.


North Carolina Division of Medical Assistance (Medicaid) Issues Guidance on Retention of Paper Prescriptions and Auditing Procedures (click here to read).


TAMPER-RESISTANT PRESCRIPTION PAD COMPLIANCE - Please see this letter from NC DHHS outlining further DMA guidance to providers regarding the upcoming deadlines for compliance with Federal requirements for tamper resistant prescription pads/paper. Beginning April 1, 2008, all written prescriptions for Medicaid fee-for-service recipients are required to have at least one of the industry recognized security features from one of the three categories of characteristics listed in DMA's September 6, 2007 guidance document. By October 1, 2008, written prescriptions will be required to have one industry recognized security feature from each of the three categories of characteristics to be in compliance with Federal law. Please find additional guidance regarding the requirements at:


Using Medicare Prescription Drug Coverage Before Receiving a Drug Plan Membership Card


Medicare Part D Resource Fact Sheet


Long-Term Care Association Letter HPMS


Subspecialty Groups Letter HPMS


Part D Drugs/Part D Excluded Drugs


Medicare Part D Prescription Drug Plans and Temporary First Fill Policies


CMS Process to Ensure Effective Transition to Medicare Part D Prescription Drug Coverage


Quick Answers to FAQs on Processing Claims for Dual Eligible Beneficiaries


Information to Assist Pharmacists in Completing Pharmacy Transactions


Pharmacy Transition Policies Reminder


For CSR Describing the POS "WellPoint" Process to a Pharmacy



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