Vaya Health connects Behavioral Health and Intellectual/Developmental Disabilities Tailored Plan Medicaid members to a large pharmacy network to access needed medications as part of the Vaya Total Care health plan.
Vaya works with a Pharmacy Benefit Manager called Navitus Health Solutions to help you get the medications you need. For help, call the Pharmacy Service Line at 1-800-540-6083, 7 a.m. to 6 p.m., Monday-Saturday, including holidays.
Vaya does not manage pharmacy services for NC Medicaid Direct members or State-funded services recipients. For more information, refer to the NC Medicaid Direct Member Handbook or Recipient Handbook.
Pharmacy network and benefit information
How do I find a pharmacy?
To find a pharmacy near you that is in the Vaya network, use the “Find A Pharmacy” tool or call our Pharmacy Service Line at 1-800-540-6083. You can use these tools to help you find pharmacies that provide additional services, like home delivery.
Your Medicaid ID card includes important information about your pharmacy benefit. Make sure you bring your Medicaid ID card when you go to the pharmacy.
What does my pharmacy benefit cover?
Vaya’s pharmacy benefit for Vaya Total Care members includes:
- 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
- Smoking cessation agents, including over-the-counter products
- Emergency contraception
Which prescriptions are covered?
The list of drugs covered by Vaya and approved by NC Medicaid is called the prescription drug formulary, or the Preferred Drug List (PDL). This list includes a wide selection of generic and brand name medicine and helps make sure you can get the medication you need. To find out if a drug is covered, visit the Find a Drug page, review the PDL, or call the Pharmacy Service Line at 1-800-540-6083.
How much will my prescriptions cost?
Your prescriptions will cost $4. Some members and prescriptions are exempt from copays. For a full list of copay exemptions, visit the North Carolina Department of Health and Human Services (NCDHHS) website. If you cannot afford your copay at the time you pick up your medication, the pharmacy may be able to give you the medicine and bill you later. You should not have to go without your medicine because you cannot afford your copay.
If you go to a pharmacy that is not in the Vaya network, you may have to pay full price for the prescription. You may be able to receive a full or partial refund for a covered medication by submitting a claim to Vaya. Complete the Prescription Drug Claim Form and return it to the address listed on the form.
Vaya Pharmacy Lock-in Program
The Pharmacy Lock-in Program helps identify members who are at risk for possible overuse or improper use of pain or anxiety medications. The program also helps identify members who get these medications from many prescribers (doctors, nurse practitioners, or physician assistants). If you qualify for this program, Vaya will pay for your pain medications and anxiety medications only when:
- Your medications are ordered by one or two prescribers. You will be given a chance to pick a prescriber in Vaya’s network.
- You have these prescriptions filled from one or two pharmacies. You will be given a chance to pick a pharmacy in Vaya’s network.
If you qualify for the Vaya Lock-in Program, you will be in the program for two years. If you do not agree with our decision that you should be in the program, you can appeal our decision before you are placed in the program. Call the Vaya Member and Recipient Service Line at 1-800-962-9003 for more information on appeals.
For more information on the Lock-In Program, contact the Pharmacy Service Line at 1-800-540-6083 or review MC Medicaid Clinical Coverage Policy 9, Outpatient Pharmacy.
Medication coverage and limits
Your provider may prescribe a drug that requires a review before the pharmacy can fill it. The review makes sure the drug is the safest, most effective, and most cost-efficient option for you before you start taking it. This review is called prior authorization. The prior authorization process is conducted by a clinical pharmacy team. There are many reasons prior authorization might be required, including:
- The drug or drug category has clinical criteria.
- The drug is non-preferred on the prescription drug formulary.
- The drug’s dosage or quantity exceeds NC Medicaid’s limits.
Pharmacy clinical coverage criteria are available for review on the NC Medicaid website. For more information and access to pharmacy prior authorization request forms, visit the Pharmacy Prior Authorization page of Vaya’s Provider Central website. You can also review Vaya’s Utilization Management Program and Policy as needed.
If prior authorization is required, your pharmacy will let you know and begin the process. The pharmacy may be able to provide you with a 72-hour supply of the medicine while the authorization is processed. Your prescriber will work with your pharmacist and Navitus to provide the needed information. A clinical pharmacy team will decide to approve or deny the authorization within 24 hours of receiving the information. If it is approved, Navitus will notify you and your prescriber, and your pharmacy will be able to fill the medication.
If prior authorization is not approved, you and your prescriber will receive a notification letter, and we will work with your doctor to find another medication. Your notification letter will tell you how to file an appeal.
You should not have to go without your medication during an emergency or a disaster. Visit our Emergency and Disaster page to learn more about how Vaya can support you.
Vaya clinical pharmacists provide chart reviews as part of Vaya Tailored Care Management. These reviews look for interactions between medications. The pharmacists look for high and low medication doses. The clinical pharmacists also think about side effects and work with Vaya nurses and Care Managers to help you get or stay healthy.
Some medications are limited. The amount you can get may be limited. You also may need to try other medications before you can get certain medicines. Your doctor may need to provide information on why a medicine is right for you. The limits you may see include:
- Prior Authorization – Your prescriber may prescribe a drug that requires a review before the pharmacy is able to fill it. Visit the Find a Drug webpage to learn if your medicine requires prior authorization. Pharmacy clinical coverage criteria are available on the NC Medicaid website.
- Quantity Limit – You may be able to get only a limited amount of a medication every month. Quantity limits help make sure the medication is safe for your clinical condition. They also help make sure you are using the least amount of medicine necessary for your condition. Visit the Find a Drug webpage to learn if your medicine has a quantity limit.
- Generic Substitution – NC Medicaid requires the use of generic medication, when available, unless your prescriber says the brand name is medically necessary. In some cases, NC Medicaid may prefer the brand name instead of the generic medication. See the PDL for more details.
Each medicine on the PDL is assigned a tier (a level of coverage). Medicaid members pay the same copay for all medicines, but Vaya and NC Medicaid promote the use of preferred medication when it is right for you.
The tiers are:
- PDL Preferred – This tier includes medications that are more cost-effective for the NC Medicaid Managed Care program.
- PDL Non-Preferred – This tier mostly consists of moderate-cost generic and brand-name prescription medications. You can get these medications when you have tried the PDL preferred medicine and it does not work for you, or if your prescriber says the preferred medicines are not right for you.
- Non-PDL – This tier includes medicines that NC Medicaid does not manage through the PDL because they do not fall within a PDL category. These medications are covered when they are part of the Medicaid Drug Rebate Program. These medicines are available to Vaya members within the limits set by the U.S. Food and Drug Administration.
- Excluded – This tier of medications is not covered by NC Medicaid. State and federal law ban Vaya from covering these medications, even with prescriber approval.
NCDHHS established the PDL List to allow NC Medicaid to ensure access to cost-efficient, medically appropriate drug therapies that maximize health outcomes for all beneficiaries. PDL updates occur quarterly.
Download the current updates PDF:
April 2025 Formulary Changes
July 2025 Formulary Changes
October 2025 Formulary Changes
January 2026 Formulary Changes
April 2026 Formulary Changes
