Gov. Joe Lombardo (R) convened a special session of the state Legislature on November 13 to address several key issues, including expanding healthcare access and workforce training.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
The latest Medicaid Pharmacy Newsletter, dated November 2025, is now available on the Medicaid website. In addition to the December 2025 check write schedule, this edition of the newsletter includes the following articles:
Providers are encouraged to review this important information. The 2025 Medicaid Pharmacy Newsletters can be viewed here.
Also in North Carolina, effective December 7, the Electronic Funds Transfer (EFT) Attestation will be added to the reverification provider application and to full Manage Change Requests (MCRs) when active electronic funds transfer (EFT) information is present. This attestation requires a signature from the Office Administrator (OA) on the provider's record.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
The state's single Medicaid PBM, Gainwell, announced that, effective December 8, claims for preferred GLP-1 receptor agonists (listed below), will require a diagnosis of 'diabetes mellitus, type 2' to be documented in the member's medical record (as determined by medical claims data) or submitted on the pharmacy claim. For members with a diagnosis of 'diabetes mellitus, type 2' documented, claims will continue to be eligible for coverage under the state's Medicaid pharmacy benefit. For all other non-FDA approved uses (such as prediabetes or weight loss), coverage will not be available. Please note claims and associated diagnoses are subject to audit, and results will be reviewed by the Department of Medicaid for compliance. Diagnosis codes must be submitted by the prescriber on the original prescription or added by the pharmacy in consultation with the prescriber, with documentation of the date, time and name of the individual providing the diagnosis, in addition to the name of the pharmacy staff member verifying the diagnosis.
Preferred GLP-1 receptor agonists include:
For more information, contact NACDS’ Jill McCormack at 717-592-8977.
The legislature convened an interim hearing to examine the influence of PBMs on prescription drug pricing and patient access to local pharmacies. Chaired by Sen. Spencer Kern (R) and pharmacist Rep. T.J. Marti (R), the session highlighted significant concerns regarding below-cost pharmacy reimbursements, opaque pricing structures and patient steering practices. Expert testimony by Antonio Ciaccia, 46brooklyn Research, and others underscored systemic incentives that diminish transparency and raise costs. The Attorney General’s office and the Insurance Department reported recovering $32 million through enforcement actions, positioning Oklahoma as a national leader in PBM oversight. Legislators signaled intent to pursue comprehensive PBM reform legislation again in 2026, aimed at enhancing transparency, safeguarding independent pharmacies and ensuring equitable drug pricing.
For more information, contact NACDS’ Mary Staples at 817-442-1155.
Effective for dates of service on or after December 1, the Department of Health and Human Services (SCDHHS) is updating its billing policy for providers who purchase physician-administered drugs through the Health Resources and Services Administration’s (HRSA) 340B drug pricing program. The changes described in this bulletin only apply to services rendered to Healthy Connections Medicaid members in an outpatient setting who are enrolled in the fee-for-service Medicaid program.
These policy updates will be published in the Physicians Services, Clinic Services, Hospital Services and Federally Qualified Health Center (FQHC) Services provider manual by December 1, 2025.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
The deadline to submit an attestation of low-volume status and proof of actual prescription volume to your contracted PBMs is December 1. Volume status is based on your pharmacy’s actual prescription volume from July 1, 2024, to June 30, 2025. For more information, please refer to the Department of Commerce and Insurance (TDCI) rules. The Tennessee Pharmacists Association’s PBM resource page also has some helpful information to assist you with this process.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
The Department of Health Care Service posted the following on the Medi–Cal Rx Web Portal: Mass Adjustment for Member Eligibility Data That Impacted Claim Funding for Claims Submitted March 10, 2022, through October 5, 2025.
For more information, contact NACDS’ Sandra Guckian at 703-774-4801.
The Board of Pharmacy shared the following updates. As a reminder, pharmacy practice documents, regulations and other resources are available on the website.
Policy 2020-15: Scope of Practice
Updates to this policy define "handling" of medications and that it requires an individual pharmacy license as well as defining the "prescription area" and who may access it.
New Pharmacy Labeling Requirement
Pharmacies must now label Schedule VI medications prescribed for reproductive or gender-affirming care with the name and address of the healthcare practice instead of the individual prescriber upon request from the prescriber.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
Effective November 6, Yeztugo® was covered as a pharmacy benefit by NYRx, the Medicaid Pharmacy Program, in addition to being covered by the Medicaid managed care medical benefit as a Practitioner-Administered Drug (PAD). To prevent pharmacy claim denial, it is important for the pharmacy to submit the claim for both oral and subcutaneous products on the same date of service.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.
