Pharmacy

What Pharmacy Benefits are covered?

Carolina Complete Health covers most prescription medications and over-the-counter drugs when prescribed by a Carolina Complete Health provider. The pharmacy program does not cover all drugs. Some drugs require prior authorization and may have limitations on age, dosage, or maximum quantities.

Which Drugs are covered?

The Preferred Drug List (PDL) is a list of drugs covered by Carolina Complete Health. Carolina Complete Health works with the State of North Carolina to ensure that medications used to treat a variety of conditions and diseases are covered. The Preferred Drug List includes drugs you receive at retail pharmacies. Carolina Complete Health adheres to the NC Medicaid Preferred Drug List.

• The Preferred Drug List (PDL) allows NC Medicaid to obtain better prices for covered outpatient drugs through supplemental rebates. The PDL was authorized by the NC General Assembly Session Law 2009-451, Sections 10.66(a)-(d).
  • Prescribers are encouraged to write prescriptions for “preferred” products.
  • Prescribers may continue to write prescriptions for drugs not on the PDL.
  • If a prescriber deems that the patient’s clinical status necessitates therapy with a non-preferred drug, the prescriber will be responsible for initiating a prior authorization request.
  • Prior authorization requirements may be added to additional drugs in the future.
  • Submit Proposed Clinical Policy Changes to the PDL
  • Preferred Drug List Review Panel
    

To view the Preferred Drug List, visit the Manuals and Forms page.
To view the Utilization Management Policy, visit the Manuals and Forms page.
To view the Prior Approval Forms, visit the Provider Pharmacy Resources page.

You can request a copy of the Preferred Drug List by calling Member Services at 1-833-552-3876 (TTY: 711).

Search the Formulary

Use the formulary search tool to find out if your medication is covered by Carolina Complete Health. The tool allows you to search through all brand and generic medications covered on the pharmacy outpatient benefit. These medications may be picked up at an in network pharmacy or sent to your home or provider’s office. Click here to access the formulary search tool.

Specialty Drugs

A specialty drug is a prescription drug that requires special handling, administration, or monitoring. These are usually ordered through a specialty pharmacy.

How Do I Get Medications?

You can have your prescriptions filled at a Carolina Complete Health network pharmacy. At the pharmacy, you will need to give the pharmacist your prescription from a Carolina Complete Health prescriber and your Carolina Complete Health ID Card. If you need help finding a pharmacy near you, call us at 1-833-552-3876 (TTY: 711).

Can I Get a Prescription with More Than a 30-day Supply?

Carolina Complete Health members are allowed a 90-day supply of most maintenance medications, such as medicine used to treat high blood pressure, diabetes, high cholesterol pressure, or other chronic conditions. Members are allowed to fill a 365 day supply of birth control. Controlled substances are not eligible for an extended supply.

Where Can I Get My Prescription Filled?

To find a pharmacy that is in the Carolina Complete Health network, you can use the Find a Provider tool. Type in your city or zip code. Then click Update. Choose Other and type the name of your pharmacy. You can also select the pharmacy type in the Select Specialty area. Only those pharmacies in the Carolina Complete Health network are listed.

How can I submit for prescription claim reimbursement?

If you paid out-of-pocket for a covered medication or product with active coverage; you may submit a Medicaid Prescription Claim Reimbursement Form (PDF) with required information. Reimbursement is not guaranteed; claims are subject to plan limitations, exclusions and provisions.

Recent Updates