Pharmacy Point of Sale (POS) claims for members enrolled in Behavioral Health and Intellectual/Developmental Disabilities (I/DDs) Tailored Plans will be temporarily managed by NCTracks when Tailored 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 as a result of a key Pharmacy Benefit Manager (PBM) unexpectedly leaving the NC Medicaid market in late 2021, requiring some Tailored Plans to procure another PBM.
- During this period NCTracks will manage pharmacy POS claims, pharmacy Prior Approvals (PAs), and the Lock-In program.
- The Tailored Plans will manage all medical claims during this period, including medical Durable Medical Equipment (DME) claims and medical drug claims (i.e., drugs billed on a CMS-1500 or a UB-04).
- DME billed on a medical claim must be submitted to the Tailored Plan.
- DME billed at Pharmacy POS must be processed by NCTracks.
Impact to Tailored Plan Members
- 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.
- Members should use the Tailored Plan contact/call center line for questions about their pharmacy benefits.
- The call center number will appear on their ID card.
- Calls will be routed to the NCTracks Call Center or the NC Medicaid Contact Center from this single portal of entry, as needed.
Impact to Pharmacists and Providers
To appropriately process pharmacy POS claims for Tailored Plan enrolled members from Dec. 1, 2022, through March 31, 2023, pharmacies must submit pharmacy POS claims for members who are enrolled in a Tailored Plan to NCTracks. The NCTracks POS information is listed below:
- BIN: 610242
- PCN: 781640064
To submit pharmacy PAs for Tailored Plan enrolled members from Dec. 1, 2022, through March 31, 2023, providers must submit pharmacy PAs to NCTracks via NCTracks’ Provider Portal or:
- NCTracks Fax: 855-710-1969
- NCTracks Pharmacy PA Call Center: 866-246-8505
Pharmacy Overrides Available at Tailored Plan Launch
From Dec. 1, 2022, through March 31, 2023, NCTracks will not receive any new medical claims information for Tailored Plan enrolled members. Medical data, which may be used by NCTracks to process automated prior authorization requirements, may not be present at POS during this period. This applies to any new medical data managed by the Tailored Plan between Dec. 1, 2022, through March 31, 2023; providers may be required to submit PA in these instances.
To mitigate impact to providers, Pharmacists may utilize PA type code "1" or submission clarification code "2" to override a rejection due to PA being required for the drugs or drug classes listed below:
- Anticonvulsants
- Xifaxan
- Antipsychotics
- Oral Pulmonary Hypertension Agents
For more information, please refer to the Pharmacy Point of Sale for Tailored Plan Launch fact sheet.
Contact
NCTracks Call Center: 800-688-6696