Frequently Asked Questions
How do I submit documentation for ASAP (Adult Safety with Antipsychotic Prescribing) and A+KIDS (Antipsychotics Keeping It Documented for Safety) programs?
Prior authorizations can be submitted to Prime Therapeutics via the Prime Therapeutics Provider Portal by clicking this link to access Cover My Meds or via fax: 866-422-8981 or phone: 844-620-6116
Where do I find information on the ASAP (Adult Safety with Antipsychotic Prescribing) and A+KIDS (Antipsychotics Keeping it Documented for Safety) programs?
Prior authorizations can be submitted to Prime Therapeutics via the Prime Therapeutics Provider Portal by clicking this link to access Cover My Meds or via fax: 866-422-8981 or phone: 844-620-6116
Does a Prior Authorization (PA) guarantee payment?
Prior Authorization is not a guarantee of payment and only approves the medical necessity and appropriateness of the drug being requested and authorized. The determination for claims payment is made when the drug claim is submitted for processing.
How often does the prescriber have to request a PA for a given drug?
A PA renewal can be requested after the initial PA approval expires. In general, a PA is approved for one year duration, therefore due for renewal request after one year. There are a few drug/drug categories that may be approved for less than a year as specified on the policy (e.g approved for some weeks or several months). A prescriber may also specify that only a limited duration of approval is needed.
Is the dispensing pharmacist notified of the PA decision?
Prior authorizations can be submitted to Prime Therapeutics via the Prime Therapeutics Provider Portal by clicking this link to access Cover My Meds or via fax: 866-422-8981 or phone: 844-620-6116
Can pharmacists initiate PAs?
No, a dispensing pharmacist cannot initiate a PA request, except pharmacists servicing LTC beneficiaries. If the recipient arrives at the pharmacy and receives a claim denial, the pharmacist should contact the prescriber and have them initiate a PA request. Pharmacists can call the Prime Therapeutics Call Center to check on the status of the PA at any time.
Can a Long Term Care Pharmacist who maintains a patient chart, initiate the PA?
An LTC Pharmacist can initiate the PA for all drugs except Brand Name Schedule II (CII) Narcotics and Sedative Hypnotics.
How often will the PA list be updated?
The PA list and criteria may be updated at different times during the year. All changes will be posted on the website.
Can a prescriber’s nurse or office manager call in a PA request?
Yes, a prescriber may designate calling in a PA request to another member of the medical team (e.g nurse, office staff, etc).
Where can I get the PA criteria?
All PA criteria are available on the Prime Therapeutics website.
How does the 72-hour supply work for pharmacists, in terms of reimbursement?
Pharmacists can bill for a 72-hour emergency supply (for instance, on a Friday evening after the doctor's office is closed). The pharmacist would then need to contact the prescriber on Monday morning and have them contact Prime Therapeutics to initiate a PA request. After the PA approval, the remaining script balance can then be be billed and dispensed.
Can a prescriber initiate a PA request before the recipient arrives at the pharmacy and receives a claim reject?
Yes; the prescriber or prescriber’s representative can contact Prime Therapeutics to initiate a PA request prior to the recipient arriving at the pharmacy and prior to a claim rejection.
What is the fastest way to receive a PA outcome for a prescriber?
The fastest way to receive a PA outcome is to submit the PA request via the secure Prime Therapeutics Provider portal or call the call center.
What is the expected turn around for a PA request?
Most PA requests will be completed during the initial contact, and usually within 24 hours. To expedite the process, it is recommended that the PA request be as complete as possible to eliminate the need for Prime Therapeutics making additional outreach to gather additional information necessary for PA review.
Is the Pharmacy PA Call Center open on holidays?
Yes, the Pharmacy PA call center is open 7am-6pm EST on all NC State observed holidays.
How will providers know when a PA expires?
The claim will begin to reject at the pharmacy after the PA expires. The approval letter also contains the duration of approval.
Can patients call for their PA status?
Yes, the patient can call to find the status of a prior authorization, but only a prescriber can initiate a PA request.
How are providers notified of updates to the program?
Via monthly bulletins published on the website.
Is a phone request sufficient for PA, or must the prescriber follow up with the PA form?
A phone request is sufficient, as the call center representative will take down the necessary information while on the phone. Exception: Opioid analgesics require a PA form or portal request (those cannot be called in).
If a prescriber feels the treatment is urgent, what can be done to expedite the PA process?
The most expedient means is to complete the PA request on the portal or call the call center. For urgent treatments, the pharmacy may also bill for a 72hr emergency supply while the beneficiary awaits the outcome of the PA.
Must the RX copy accompany the PA request form?
No, the RX copy does not need to accompany a PA request form.
Are retroactive approvals possible?
We have the capability to back date a prior authorization. Requests for this service will be considered case by case.
How long does it take to process a prior authorization request?
Prior authorizations can be submitted to Prime Therapeutics via the Prime Therapeutics Provider Portal by clicking this link to access Cover My Meds or via fax: 866-422-8981 or phone: 844-620-6116
Do I need to document prior approval?
Most requests for prior approval can be done over the phone, and the prescriber need not document the request or the approval. Prime Therapeutics will enter authorizations into the POS online processing system so that pharmacists will be able to fill prescriptions.
I'm a pharmacist. How will I know prior authorization has been obtained?
You may re-run the claim to confirm if it will pay. If prior authorization has not been obtained for prior approval drugs, POS system will the reject the claim. You may also contact the prescriber or Prime Therapeutics call center to check on the status.
As a pharmacist, can I ever fill a prescription when prior authorization has not been obtained?
Should a pharmacy need to dispense medication to a recipient in an emergency, the pharmacist can bill for a 72-hour emergency supply pending when the prior authorization is approved.
If a PA is approved for 1 year, does that cover every script for the approved drug for that time period? (For example, if prescriber writes a 30 day supply on each script, do they need a new PA each month?)
Yes it does cover every prescription for the approved drug for 1 year.
How do find the new BIN, PCN and Group?
As of 8/1/2025 the new BIN is 026795, the new PCN is 1116240801 and the new Group is NCMEDICAID.
What is the System availability for submitting claims?
Prime Therapeutics State Government Solutions is available for claims submission daily (24/7/365). Occasionally maintenance will need to be done to the system and that will typically occur on Sundays from 12:00 A.M. to 2:00 A.M. CT. If maintenance is not needed, the system will remain available for claims processing.
How do I request a new or replacement pharmacy ID card?
Please contact Department of Social Services (DSS) at 888-245-0179
Who can I call about my pharmacy benefits?
Starting 8/1/2025, please contact the Prime Therapeutics Call Center at 844-620-6116
What if my pharmacy claim is denied?
Starting 8/1/2025, please contact the Prime Therapeutics Call Center at 844-620-6116