Frequently Asked Questions

Effective May 2, 2026, pharmacy benefit inquiries for NC Medicaid Direct beneficiaries should be directed to the Prime Call Center at 844-620-6116.

No. Prime serves as the Pharmacy Benefit Administrator (PBA) for NC Medicaid Direct. The State retains ownership and oversight of pharmacy policy, reimbursement and formulary decisions.

For replacement or new Medicaid ID cards, please contact the Department of Social Services (DSS) at 888-245-0179.

These FAQ's apply to NC Medicaid Direct beneficiaries. Pharmacy benefit questions for beneficiaries enrolled in PHP should be directed to the beneficiary’s health plan.

Yes. The Pharmacy PA Call Center operates 24 hours per day, 7 days per week, 365 days per year, including NC State-observed holidays. Phone: 844-620-6116 Fax: 866-422-8981 (Effective May 2, 2026).

Yes. Prime maintains protected health information (PHI) in accordance with HIPAA, state privacy laws, and contractual data security requirements.

Certain medications are subject to PA based on clinical guidelines, cost considerations, utilization management standards, and program policy to ensure appropriate and medically necessary use.

All PA criteria and associated forms will be available on the Prime PBA website under the Forms and Documents section.

Program updates are communicated through NC Medicaid bulletins and posted on the Prime PBA website. Providers are encouraged to monitor the website regularly for the most current information.

Prescription drugs billed through the NC Medicaid Pharmacy Program are subject to PA requirements as applicable. Medications administered in a prescriber's office that are billed under the medical benefit are to processed through the Pharmacy program. IV medications administered in the home and certain drugs dispensed to nursing facility residents may be covered under the Pharmacy Program and may therefore require PA.

No. Prior Authorization confirms medical necessity and policy compliance at the time of review. It does not guarantee payment. Final claim adjudication remains subject to beneficiary eligibility, benefit coverage, and all other applicable program requirements at the time the claim is submitted.

Prime representatives may access claims history information for treatment and operational purposes in accordance with HIPAA and program guidelines. Information may be shared with the prescriber or authorized representative as permitted by law.

Prior authorizations approved prior to the transition will remain valid through their original approval period.

Yes. A prescriber may designate a beneficiary of their clinical staff (e.g., nurse or office staff) to submit or call in a PA request. The prescriber remains responsible for the accuracy and completeness of submitted information.

No. A dispensing community pharmacist may not initiate a PA request. If a claim rejects for PA, the pharmacist must contact the prescriber to initiate the request. Pharmacists may contact the Prime Call Center at 844-620-6116 to check the status of a submitted PA.

A LTC pharmacy may initiate a PA request for NC Medicaid Direct beneficiaries for all drugs except Brand Name Schedule II (CII) narcotics and sedative hypnotics, in accordance with program policy.

The PA request should be submitted by the prescribing provider responsible for the medication order. An authorized representative may submit the request on the prescriber's behalf if all required clinical information is available.

When a PA request is submitted via fax or paper form, it must include the signature of the prescribing provider or their authorized representative, as required by program policy.

Yes. A prescriber or authorized representative may submit a PA request to Prime prior to the beneficiary presenting at the pharmacy and prior to a claim rejection.

No. A prescription copy is not required to accompany the PA request unless specifically requested during review.

The fastest and preferred method to receive a PA determination is to submit the request through the secure Prime Provider Portal.

To expedite review, prescribers should submit the PA request through the Prime Provider Portal or contact the PA Call Center and clearly indicate the urgency of the request. In accordance with NC Medicaid policy, a pharmacist may dispense a 72-hour emergency supply when appropriate while the PA determination is pending.

A phone submission is sufficient for most PA requests, as the call center representative will collect the necessary clinical information during the call. Exception: Certain medications (e.g. opioid analgesics) require submission via the Provider Portal or an approved PA form and cannot be completed solely by phone.

Most PA requests are reviewed promptly and may be resolved during the initial submission when sufficient clinical information is provided. Standard requests are generally processed within 24 hours; however, turnaround times may vary depending on the completeness of the information submitted. Providers are encouraged to submit complete documentation to avoid delays.

Retroactive PA requests may be considered on a case-by-case basis in accordance with program policy. Approval is not guaranteed.

A PA renewal request must be submitted prior to the expiration of the existing authorization. In general, PAs are approved for up to one year unless otherwise specified in policy. Certain drugs or drug classes may have shorter approval durations as outlined in program criteria.

An approved PA generally covers the authorized drug for the approved duration, including refills, unless otherwise specified in the approval criteria. Quantity limits, dosage restrictions, or other policy requirements may still apply.

There is no specified limit on resubmission of a PA request. If additional clinical information is available following a denial, a revised request may be submitted for reconsideration. If a change in dosage or quantity is required after approval, the prescriber should contact Prime to determine whether the change can be accommodated or if a new PA submission is required.

The PA approval letter specifies the authorization duration and expiration date. Once a PA expires, subsequent claims will reject at the point of sale. Providers are responsible for submitting renewal requests prior to expiration.

Prior authorizations (PA) requests for NC Medicaid Direct beneficiaries must be submitted to Prime via the Prime Provider Portal (CoverMyMeds) at https://www.covermymeds.health/prior-authorization-forms/prime, by fax: 866-422-8981 or phone: 844-620-6116. The Provider Portal is the preferred and fastest submission method.

Information regarding the ASAP and A+KIDS programs, including prior authorization requirements and criteria, is available on the Prime PBA website for NC Medicaid Direct beneficiaries.

Yes. A beneficiary may contact Prime to inquire about the status of a PA request. However, only a prescriber or authorized representative may initiate or modify a PA request.

In accordance with NC Medicaid policy, a pharmacist may dispense a 72-hour emergency supply when a medication requires PA and the prescriber is unavailable. The prescriber must subsequently submit a PA request to Prime. Upon approval, the remaining quantity may be dispensed and billed consistent with program requirements.

PA requests are reviewed promptly upon receipt. Standard requests are generally processed within 24 hours when complete clinical documentation is provided. Turnaround times may vary depending on the complexity of the request.

Most prior authorization (PA) requests may be submitted by phone or through the Prime Provider Portal. Separate documentation of approval is not required for claim submission. Approved PAs are entered into the POS claims processing system and will adjudicate accordingly.

Effective May 2, 2026: BIN: 026795 PCN: 1116240801 Group ID: Not Required (leave blank).

Provider training materials, webinars, and user guides are available on the Prime PBA website.

Pharmacists may submit the claim through the POS system to confirm approval status. If a PA has not been approved, the claim will reject. Pharmacists may also contact the prescriber or the Prime Call Center to verify the status of a PA request.

If a medication requires a PA and approval has not been obtained, the claim will reject at the point of sale. In accordance with NC Medicaid policy, a pharmacist may dispense a 72-hour emergency supply when appropriate while awaiting PA determination.

If a pharmacy claim is denied, review the reject message for details. For assistance, contact the Prime Call Center at 844-620-6116 (effective May 2, 2026).

After dispensing a 72-hour emergency supply, the pharmacy should notify the prescriber and ensure that a valid prescription and any required PA request are submitted promptly in accordance with NC Medicaid policy and federal controlled substance regulations.

The State maintains oversight of pharmacy reimbursement methodology. The transition to Prime as the PBA does not change the State's reimbursement structure.

In the event of a temporary system interruption, providers should follow standard emergency supply procedures and monitor the Prime PBA website for updates.