Outpatient Pharmacy Services

Clinical Policy and Programs
Phone - (919) 855-4300
Fax - (919) 715-1255

The N.C. Medicaid Outpatient Pharmacy Program covers prescribed drugs when they meet the guidelines and specific criteria listed in Clinical Coverage Policy #9, Outpatient Pharmacy Program.  A summary of the recent changes can be found in the July 2007, Special Bulletin, Outpatient Pharmacy Program.

The prescribed drug must have Federal Drug Administration (FDA) approved indications.  The prescribed drug must bear the federal legend statement and must be manufactured by a company that has signed a National Medicaid Drug Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS).

• Federal Upper Limit (Federal MAC)
• North Carolina Medicaid Maximum Allowable Cost (MAC) List
• State Maximum Allowable Cost (SMAC) Pricing Inquiry Worksheet

Prescription Advantage List (PAL)

• PAL Pocket Card Updated 4/7/08
• For more information about PAL (including an interactive tool), visit the NC Physicians Advisory Group website.

Selected over-the-counter (OTC) medications and insulin products are covered when they meet the criteria listed in General Medical Policy No. A-2, Over the Counter Medications.

Prior authorization is required for selected drugs prescribed to North Carolina Medicaid recipients when they meet the guide.  For additional information about medications that require authorization, refer to:

• Enhanced Pharmacy Program Website for information on Drugs that Require PA
• General Policy #A3, Prior Authorization for Outpatient Pharmacy Point of Sale Medications

Outpatient Pharmacy Special Bulletins

• January 2008, Special Bulletin, DMA Guidance for Tamper Resistant Prescription Pads New 1/3/08
• July 2007, Special Bulletin, Outpatient Pharmacy Program
• May 2006, Special Bulletin, Outpatient Pharmacy Program