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 Vaya Total Care. 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. If your family members are also Vaya members, they will need to bring their own Medicaid ID card to the pharmacy if they wish to fill a prescription.
Vaya works with a pharmacy benefit manager called Navitus Health Solutions to help you get the medications you need. For help, call our Pharmacy Service Line at 1-800-540-6083, 7 a.m. to 6 p.m., Monday – Saturday, including holidays.
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
- Medical and surgical supplies—available through durable medical equipment (DME) pharmacies and suppliers
Pharmacy services Q&A
To find a pharmacy near you that is in the Vaya network, click on the “Find A Pharmacy” tool or call our Pharmacy Service Line at 1-800-540-6083. You can use this tool or call the Pharmacy Service Line to help you find pharmacies that provide additional services, like home delivery.
Your prescriptions will cost $4 or less. If you are not able to 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 be required 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.
The prescription drug formulary is the list of drugs covered by Vaya and approved by NC Medicaid. This list includes a wide selection of generic and brand name medicine and is designed to make sure you can get the medication you need. To find out if a drug is covered, visit our Medication Search page or call the Pharmacy Service Line at 1-800-540-6083.
Your provider may prescribe a drug that requires a review before the pharmacy is able to 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 a prior authorization. The prior authorization process is conducted by a clinical pharmacy team. There are many reasons a prior authorization might be required, including:
- The drug/drug category has clinical criteria.
- The drug is non-preferred on the formulary.
- The drug’s dosage/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. Vaya’s full Utilization Management Program and Policy is also available for review.
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.
Vaya’s pharmacy 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). Learn more.
You should not have to go without your medication during an emergency or a disaster. Visit our Emergency and Disaster page to learn about how Vaya can support you.
Visit our Emergency and Disaster page to learn more about how Vaya can support you during an emergency or disaster.
The North Carolina Department of Health and Human Services established the NC Medicaid Preferred Drug List to allow NC Medicaid to ensure access to cost-efficient, medically appropriate drug therapies that maximize patient 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
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.
