This is advance notice of reprocessing information that will be sent to affected providers on or about January 17. Due to a system error with the generic dispensing fee, pharmacy claims were paid incorrectly. The affected claims will be reprocessed to apply the correct rate. This reprocessing notice applies to pharmacy claims that were processed and paid in NCTracks from November 1, 2013, through April 7, 2014. The affected claims will be systematically reprocessed as adjustments. No provider action is required. Applicable claims will be reprocessed in the February 7 check write. For more information, visit NCTracks here.  

For more information, contact NACDS’ Leigh Knotts at 803-243-7207. 

Ohio: The Ohio Department of Medicaid (ODM) and Gainwell Technologies, the Single Pharmacy Benefit Manager, are continuing the re-implementation of prior authorizations (PA) based on specific drug classes. Of note, the PA reimplementation only applies to new, initial authorizations, and does not apply to those patients who have previously taken the drug supported by recent claims history prior to January 17. Phase 2 of reimplementation will begin on January 17 and encompass the following drug classes:  

• Specialty Medications (PA Fillable Forms) 
• Hepatitis C Medications (Hepatitis PA Fillable Form)  

• Opioid Medications (Opioid PA Fillable Form) 

Please reference the Unified Preferred Drug List (UPDL) posted on the SPBM portal to see the products that require prior authorization. Prior authorizations may be submitted via phone, fax, mail and the SPBM portal. Additional prior authorizations are planned for reimplementation in a similar, incremental fashion during the first quarter of 2023. For questions, contact the Gainwell Help Desk at 1-833-491-0344.  

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

The mandate for health care organizations and providers that serve state-funded patients to connect to the state-designated HIE by January 1, 2023, is fast approaching. The legislative changes enacted in the 2022 Appropriations Act may leave organizations and providers with questions about their connection status. Our General FAQs on NC HealthConnex gives more answers about the impacts on NC HealthConnex participants and non-participants.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

To help providers, the Department of Health and Human Services updated its Provider Guidance on Therapeutics to include detailed up-to-date information. Providers are encouraged to read the guidance. More information is available on the Therapeutics Information for Providers webpage.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

To ensure beneficiaries can seamlessly receive care on day one, the North Carolina Department of Health and Human Services (NCDHHS) will delay the implementation of the NC Medicaid Managed Care Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans until April 1, 2023.

Tailored Plans, originally scheduled to launch December 1, 2022, will provide the same services as Standard Plans in Medicaid Managed Care and will also provide additional specialized services for individuals with significant behavioral health conditions, Intellectual/Developmental Disabilities and traumatic brain injury.

The delayed start of Tailored Plans allows Local Management Entity/Managed Care Organizations, which will operate the Tailored Plans, more time to contract with additional providers to support member choice and to validate that data systems are working appropriately. The decision is supported by the leadership of the state’s six LME/MCOs.

While the start of Tailored Plans will be delayed, specific new services will still go live December 1, 2022.

More information regarding the beneficiary choice period and other key dates leading up to the April 1, 2023, launch will be shared by NCDHHS in the coming weeks. For more information about Tailored Plans, please visit NC Medicaid’s Tailored Plan website.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Please find here a notice from North Carolina Medicaid to permanently transition to a specific dispensing fee for North Carolina Medicaid based on the Cost-of-Dispensing Study performed every five years. This fee is currently $10.24. Also, included in this notice is North Carolina Medicaid’s decision to allow for more than one dispensing fee per month. 

Also in North Carolina, see the Medicaid Special Pharmacy Newsletter providing Revised Procedures for Prior Authorization of palivizumab (Synagis®) for Respiratory Syncytial Virus Season 2022/2023 – Coverage starts Oct. 1, 2022.  

Finally, effective with date of service Aug. 31, 2022, the NC Medicaid and NC Health Choice programs cover Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) – 12 years of age and older (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91312 – Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use.   

Effective with date of service Aug. 31, 2022, the NC Medicaid and NC Health Choice programs cover Moderna COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5) – Booster Dose (N/A) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 91313 – Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use. More information.  

Providers are encouraged to review this information. All bulletin articles, including those related to COVID-19, are available on DHB’s Medicaid Bulletin webpage.  

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

on December 1, 2022, North Carolina will launch the NC Medicaid Managed Care Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans. “This plan is an integrated health plan for individuals with significant behavioral health needs and intellectual/developmental disabilities (I/DDs)” On October 12, 2022, at 8:00 am EST NC Medicaid will host an online seminar to provide valuable information about each of the contracted Tailored Plan managed care organizations, and to provide an opportunity for pharmacists to ask questions about what to expect, operational changes and processes. The target audience for the Webinar includes pharmacy owners, managers and those who submit pharmacy benefit claims for Medicaid beneficiaries. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The North Carolina COVID-19 state of emergency sunsets on August 15, 2022. For more information on how it affects pharmacy practice please click here. 

Also in North Carolina, pharmacy claims processing under Behavioral Health and Intellectual/Developmental Disabilities (I/DDs) Tailored Plans. Pharmacy Point of Sale (POS) claims for members enrolled in Tailored Plans will be temporarily managed by NCTracks when the plans launch on Dec. 1, 2022, through March 31, 2023. Beginning on April 1, 2023, these claims will be managed by the Tailored Plans. This change was made due to a key Pharmacy Benefit Manager (PBM) unexpectedly leaving the NC Medicaid market in late 2021, which required some Tailored Plans to procure another PBM. 

There will be no impact to members’ pharmacy benefits during this transition period. From Dec. 1, 2022, through March 31, 2023, member ID cards will not include pharmacy information. A new card will be issued for April 1, 2023, indicating the new RxBin and PCN numbers for the Tailored Plans. 

NC Medicaid will reach out to members, pharmacists, and providers in the coming months with additional information about this transition. For more information, please see the Medicaid bulletin Pharmacy Point of Sale Process at Tailored Plan Launch.  

Finally, please see August 2022 NC Medicaid Pharmacy Newsletter which contains information on the below.  

•  NC Medicaid Pharmacy Point-of-Sale Billing for Pharmacist-Prescribed Paxlovid 
• October 2022 Drug Use Review (DUR) Board Meeting 
• Reminder Regarding the Naloxone Standing Order  
• Pharmacy Point of Sale Process at Tailored Plan Launch   

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

All immunizing pharmacists who vaccinate NC Medicaid beneficiaries, NC Medicaid wants to hear from you on how you bill for vaccine and vaccine administration to NC Medicaid. Please take 1 minute to answer three simple questions to help us determine if we can help make claims processing an easier process for you. Please respond by August 1, 2022.

Also in North Carolina, the Board of Pharmacy has been made aware that a pharmacy has implemented a policy whereby its prescription processing system will not allow an NP- or PA-issued prescription to be processed without the supervising physician’s name and other information.

A supervising physician’s information is not required on NP (Nurse Practitioners)- or PA-issued prescriptions. On February 1, 2021, the NC Medical Board amended the prescribing authority rule for physicians’ assistants by removing the supervising physician information requirement for prescriptions written by physicians’ assistants.

On August 1, 2021, the NC Medical Board amended the prescribing authority rule for nurse practitioners by removing the supervising physician information requirement for prescriptions written by nurse practitioners.

Prior to the Medical Board’s 2021 rule amendments (as detailed in long-standing Board guidance, see Item 2403), the absence of a supervising physician’s name and telephone number did not render a PA- or NP-issued prescription “invalid,” “illegal,” or otherwise ineligible for dispensing under the North Carolina Food Drug and Cosmetic Act or the North Carolina Pharmacy Practice Act.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Governor Roy Cooper (D) has signed the 2022/2023 budget. Of importance to NACDS (National Association of Chain Drug Stores) members, language was added to extend from June 30, 2023, to June 30, 2026, pharmacy reimbursement being tied to the fee-for-service rate of NADAC (National Average Drug Acquisition Cost) plus a $10.24 dispensing fee. Language was also added to extend the State Health Director’s authority to issue statewide standing orders for COVID tests and vaccines until December 31, 2023 and maintains all the current statewide standing orders currently in place until rescinded by the State Health Director. This will ensure Pharmacies will continue to get reimbursed for the administration of the COVID vaccination and tests by North Carolina Medicaid. Finally, a provision was added to reauthorize the dispensing of biosimilars and the requirement for pharmacists to input patient information into a system that can be accessed by prescribers for biosimilar interchangeable. This can be achieved by processing the prescription through a PBM (Pharmacy Benefit Manager) or an electronic health record.  

Also in North Carolina, the Department of Health and Human Services is establishing Community Access Points in all 100 counties where North Carolinians can find free and easy at-home tests, to meet people where they are, with the tools they need to protect themselves from COVID-19.
Community organizations interested in becoming a Community Access Point can register online. Information on where to find at-home tests is available at: covid19.ncdhhs.gov/PickUpTests. Information on how and where to find all testing locations in North Carolina is available at: covid19.ncdhhs.gov/FindTests. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.