Starting Oct. 1, 2026, some members will see a difference in how pharmacy copays are applied. This change is to align and be consistent with North Carolina’s Medicaid copay rules. As a result, some members with an intellectual/developmental disability (I/DD) will have a $4 copay when they fill a prescription.
Not every member with I/DD will have to pay a copay. For example, you will not have a pharmacy copay if you are enrolled in the NC Innovations Waiver.
What is happening?
Effective Oct. 1, 2026, some members with an I/DD will have a $4 copay when they fill a prescription. This change is to align more closely with North Carolina Medicaid copay rules.
What does this mean for members?
- Some I/DD members will have to pay a $4 copay when they fill a prescription.
- The copay will not apply to all I/DD members, including members who are:
- Enrolled in the NC Innovations Waiver.
- Pregnant
- In foster care
- Residing in certain facilities
- Review the full list of exemptions is available on the NC Medicaid Copays
What do providers need to do?
- Provide services to any Medicaid beneficiary regardless of the individual’s ability to pay.
- Federal Medicaid rules state that a provider may not deny services to an individual because of the individual’s inability to pay.
- This applies to all providers, including pharmacies, enrolled in the NC Medicaid program.
- Open an account for the beneficiary and collect the amount owed later. (The member is still responsible for the copay.)
- Let the member know they can get maintenance medications for 90 days at a time. (The provider and pharmacy should talk to the member about whether their medication qualifies for 90-day supplies.)
- This means the member will pay one copay instead of three over the three-month period.
Who can providers contact if they have questions?
- Providers can call the Provider Services Line at 1-877-398-4145 (Partners) or 1-866-990-9712 (Vaya).