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.