MedicaidPrior AuthHigh impact
Utilization Management by NC Medicaid Managed Care Health Plans – August 2026
NC Medicaid - NCDHHS·NC · Pharmacy·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Aug 11, 2026
Summary
NC Medicaid Managed Care health plans now have clarified authority to apply utilization management and prior authorization strategies for pharmacy drugs (outpatient, outpatient hospital, and physician-administered) based on FDA labeling and Medically Acceptable Indications, except where red-text notations on the PDL or posted clinical criteria in Prime Therapeutics/NCTracks prohibit additional UM. This policy replaces the previous UM bulletin and establishes new restrictions effective July 1, 2026 for the Physician Administered Drug Program.
Action Required
By July 1, 2026: Billing team must audit all NC Medicaid Managed Care pharmacy claims (outpatient pharmacy, outpatient hospital, and physician-administered drugs) to identify which drugs require prior authorization. (1) Review the NC Medicaid Preferred Drug List (PDL) for red-text notations indicating where additional UM/prior auth is prohibited—do NOT apply UM to these drugs. (2) Consult Prime Therapeutics for outpatient pharmacy drugs and NCTracks for outpatient hospital and physician-administered drugs to confirm posted clinical criteria; if criteria are posted, apply ONLY those criteria, not additional UM. (3) For drugs without posted clinical criteria and without PDL red-text restrictions, implement prior authorization workflows aligned with FDA labeling and Medically Acceptable Indications. (4) Update billing software and prior auth submission protocols to reflect these distinctions by plan and drug category. (5) Train billing and clinical staff on when to request prior authorization versus when it is prohibited. Failure to comply will result in claim denials for unauthorized prior authorizations or missing required authorizations. Contact NC Medicaid Managed Care health plan representatives (AmeritHealth, Healthy Blue, Carolina Complete, United Healthcare, or specialty plans) for plan-specific UM guidelines.