Tailored Plan Medicaid Providers Pharmacy Benefits

Please Note: Pharmacy Benefits will start for Tailored Plan Medicaid members only in July 2024.

Pharmacy Benefits

• Prescription drugs
• Some medicines sold without a prescription (also called “over-the-counter”), like allergy medicines.
• Insulin and other diabetic supplies like syringes, test strips, lancets and pen needles.
• Items to help stop smoking, including over-the-counter products.
• Emergency contraception.

Trillium has partnered with PerformRx, to oversee the pharmacy benefit plan. They work to provide access to medications prescribed by psychiatric and physical health prescribers. Medications can help members improve their quality of life, experience better success in recovery, and provide positive outcomes. 

Trillium covers medications on the drug formulary established by NCDHHS. A drug formulary is the list of generic (such as acetaminophen instead of Tylenol®) and brand-name prescription drugs covered by the Tailored Plans. In most cases, a generic drug will be required to be dispensed, but the plan covers all brand medications if a generic substitution is not available. Medications are classified on the  Preferred Drug List (PDL) as Preferred, Non-Preferred, or Non-PDL.

You can search for any medications that are covered here:

Pharmacy Lock-in Program

The Trillium Lock-In Program helps identify members who are at risk for possible overuse or improper use of pain medications (opioid analgesics) and nerve medications (benzodiazepines and certain anxiolytics). The Trillium Lock-In Program also helps identify members who get the medications from more than one prescriber (doctor, nurse practitioner or physician’s assistant). If a member qualifies for this program, Trillium will only pay for pain medications and nerve medications when:

• The medications are ordered by one prescriber. They will be given a chance to pick a prescriber in the Trillium’s network. 
• They have these prescriptions filled from one pharmacy. They will be given a chance to pick a pharmacy in Trillium’s network. 

If a member qualifies for Trillium Lock-In Program, they will be in the program for a two-year period. If they do not agree with our decision that they should be in the program, they can appeal our decision before they are placed in the program (see Appeals page or the member handbook for more information).

Trillium Health Resources members will be enrolled into the lock-in program for a minimum of two (2) years if one or more of the following criteria are met:

• Member has received ten (10) benzodiazepine prescriptions within two (2) consecutive months when not medically necessary. 
• Member has received ten (10) opiate (pain management) prescriptions within two (2) consecutive months when not medically necessary..
• Member is receiving prescriptions for opiates and benzodiazepines from four (4) or more prescribers in two (2) consecutive months when not medically necessary.

Locked-in members will be restricted to one prescriber and one pharmacy at minimum for prescriptions for benzodiazepines and opiates. These requirements apply only to those drugs, for members who are in the lock-in program.

The following information is also available for prescribers:

• Visit NC Medicaid’s website for copies of Pharmacy Services Clinical Coverage Policies
• Prior authorization request forms for pharmacy use are available here:
  • Complete forms online for submittal
  • Form can be faxed in to 1-833-726-7628.
• Trillium’s Clinical Review Criteria and Utilization Management Program Policy. includes pharmacy clinical coverage and prior authorization criteria.

Drug Utilization Review Program

PerformRx has a Drug Utilization Review program to prevent issues including interactions between prescribed drugs and to identify potential abuse, along with the following:

• Drug-disease contraindications (if a drug could cause more harm than benefit if diagnosed); 
• Drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs); 
• Incorrect drug dosage or duration of drug treatment;
• Drug-allergy interactions;
• Therapeutic appropriateness (medically necessary for the individual); 
• Over- and under-utilization (whether drug is being used too frequently or not enough); 
• Use of anti-psychotic drugs in children and youth; 
• Psychotropic polypharmacy (when more than 1 mental health medication is prescribed); 
• Appropriate use of generic products; 
• Therapeutic duplication (prescribing more than 1 drug for the same condition); and
• Clinical abuse or misuse.

This review occurs when a prescription is filled at the pharmacy. 

Pharmacy Prior Authorization

Prior authorization is required for certain drugs prescribed Trillium members. Our Pharmacy Services department reviews pharmacy prior authorizations for safety and appropriateness.

Reasons a medication may require preauthorization:

• The medication is not preferred, and other alternatives are recommended.
• The dose is outside FDA recommendations.
• The medication is a high risk for abuse or misuse.
• The medication requires additional information.

See Program Specific Clinical Coverage Policies for more details, including pharmacy authorization criteria. 

How to submit a request for pharmacy prior authorizations

• Download and complete the appropriate prior authorization form from the list below. 
• Fax your completed Prior Authorization Request form to 1-877-234-4274, or call 1-866-885-1406, 7 a.m. to 6 p.m., Monday through Saturday.

If you have questions after business hours (Sundays and holidays), call Member Services at 1-877-685-2415 (TTY 1-866-735-2962).

Emergency supply

In the event a member needs to begin therapy with a medication before you can obtain prior authorization, pharmacies are authorized to dispense up to a 72-hour emergency supply.

Prior authorization forms

Download and submit the following forms to submit pharmacy prior authorization requests.