For Prescribers: Pharmacy Benefits Information
Starting December 1, 2022, Sandhills Center members will receive pharmacy benefits through the pharmacy benefits manager PerformRx. Members will be able to receive medications, durable medical equipment, vaccinations, and other covered items and services from local chains and independent pharmacies.
There also is a mail order option for individuals who have transportation or other access issues. All participating pharmacies are allowed to mail prescriptions to their patients. If a patient desires mail order service, but their pharmacy does not provide it, the patient may choose to use Deep River Drug of High Point, NC for medication delivery at no extra cost. Deep River Drug can be contacted by phone at 336-454-3784, by email, or visit the Deep River Drug website.
Managing health and pharmacy benefits concurrently allows Sandhills Center to focus on holistic health care for individuals who receive services. Prescribers and pharmacy providers can reach PerformRx for benefits information by calling 1-888-846-1062, Monday through Saturday, 7 a.m. to 6 p.m.
PREFERRED DRUG LIST
Sandhills Center and PerformRx utilize Medicaid’s open formulary with a Preferred Drug List (PDL). Generally, all medications are covered unless, within a therapeutic category, preferred drugs exist. Generic medications may be preferred over their branded counterparts, as well as other brands in the respective category. Many rebate-eligible brands and single-source entities are preferred, as well. As a general rule, medications for weight loss, cough and cold, Erectile Dysfunction, bulk chemicals, vitamins, investigational drugs, hospice drugs, and most over-the-counter (OTC) items are excluded, although there are some exceptions. Prescription vitamins such as D2, prenatal vitamins, potassium, folic acid, and fluoride are covered.
Preferred Drug List *Always select the newest PDL post to access the most current list
UTILIZATION MANAGEMENT, CLINICAL COVERAGE CRITERIA, AND PRIOR AUTHORIZATION
Drug Utilization Review (DUR) edits are a part of the PerformRx point-of-sale platform. Concurrent DURs shall include (but are not limited to) duplicate therapy, early refills and frequency limitations, duplicate drugs, potential drug interactions, PDL selection, and minimum/maximum dose range. Retrospective DUR reviews will occur on a regular basis to identify potentially inappropriate prescribing patterns and to evaluate the benefits of the DUR to reduce inappropriate medication usage.
Prior Authorizations (PAs) are possible for Non-Preferred Drugs under certain circumstances. Generally, a PA can be granted when there is a recorded treatment failure of two Preferred Drugs in a therapeutic category (unless there is only one preferred drug in that category), and meets certain diagnosis qualifications. Sandhills Center and PerformRx will follow Medicaid’s Clinical Coverage and PA Criteria.
PRIOR AUTHORIZATION REQUEST FORMS/INSTRUCTIONS
PA requests may be processed by phone, fax, U.S. mail, or electronic submission.
Prescribers can find Preferred and Non-Preferred Drug status in each therapeutic category on the Preferred Drug List.
Medicaid Clinical Coverage and PA Criteria for Non-Preferred Drugs link: Clinical Coverage/PA Criteria
Prior Authorizations can be submitted online here: PerformRx PA web submissions web form
To fax or mail Prior Authorizations: PA Fax/Mail Submission Process and Forms
For additional information and to obtain PA by phone, call PerformRx: 1-888-846-1062, Monday through Saturday, 7 a.m. to 6 p.m.
Pharmacy PAs will be processed within 24 hours from when the request is received unless it is necessary for the PA request to be pended to obtain additional information. In that case, the PA may take an additional 24 hours from receipt.
Prior Authorization also includes the A+KIDS program for documenting safety protocols for safe and efficacious prescribing of antipsychotics to NC Medicaid and Health Choice beneficiaries up to and including 17 years of age.
HOW PATIENTS CAN ACCESS MEDICATION DURING A DISASTER OR EMERGENCY
Sandhills Center encourages members to have a plan in place in case of emergencies. That plan should include always having one to two weeks worth of supplies/medication on hand. In the event of a declared state of emergency or disaster -- including those declared by the Governor of North Carolina, the Federal Emergency Management Agency, or the U.S. President -- the following protocol will be enacted at the direction of the Secretary of the North Carolina Department of Health and Human Services (NCDHHS) to prevent significant disruption to the access of lifesaving prescription medications for NC Medicaid and NC Health Choice beneficiaries:
- Waive utilization management requirements (PAs, where applicable), and lift “refill-too-soon” edits.
- Allow an affected member to obtain the maximum extended day supply, if requested and available at the time of refill. Pharmacy providers are encouraged to use the 72-hour emergency supply allowed for drugs requiring prior approval. Federal law requires that this emergency supply be available to Medicaid beneficiaries for drugs requiring prior approval. Use of this emergency supply will ensure access to medically necessary medications.
Pharmacy providers also are required to have emergency protocols to ensure they are able to offer emergency supplies to their patients, and members are encouraged to consult their pharmacists in these situations.
PerformRx also will assist pharmacies and patients to ensure emergency medication availability. Call 1-888-347-1062, Monday through Saturday, 7 a.m. to 6 p.m.