Tailored Plan Medicaid Member Pharmacy Benefits
Medications to Help in Treatment and Recovery
Trillium works with PerformRx to oversee the pharmacy benefit plan for Trillium Tailored Plan members. They provide access to medications prescribed by behavioral and physical health prescribers. Medications can help members improve their quality of life. Members in recovery or experiencing a physical health condition may see better outcomes.
How to access medications during a disaster or emergency:
Trillium will help members to fill an emergency supply of medications should a state of emergency be declared. In addition, certain members can, on request, get the maximum extended day supply of their prescriptions. Your care manager will have more information when an emergency declaration is active.
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.
July 1, 2025 - PDL Changes
Starting July 1st, 2025, some brand-name medicines will no longer be preferred. This means you will get the generic version instead. Generic medicines work the same way as brand-name ones and are approved by the FDA to be safe and effective.
Here are the changes:
- Banzel® Suspension
o You will now get: Rufinamide suspension (generic) - Derma-Smoothe/FS Scalp Oil 0.01%®
o You will now get: Fluocinolone body/scalp oil (generic) - HumaLOG Mix 75/25 KwikPen® (100 units/mL)
o You will now get: Insulin lispro protamine 75/25 KwikPen® (generic)
What This Means for You:
Your medicine may look different, but it will work the same. These changes should not stop you from getting your medicine. - Epidiolex® (eh-pid-ee-oh-lex) Solution Update
o Change: Epidiolex® is moving to non-preferred status.
Epidiolex® already needs special approval (called a prior authorization) before it can be filled.
What This Means for You:
If you are already taking Epidiolex®, this change will not affect you. You can still get your medicine like usual.
If you have questions, talk to your doctor or pharmacist.
Available Medications
The Trillium Tailored Plan covers medications on the drug formulary established by NCDHHS. A drug formulary is the list of all medications covered by a health plan. This list includes generic (such as acetaminophen instead of Tylenol®) and brand name prescription drugs covered by the Tailored Plans. The plan covers all brand medications if a generic substitution is not available. In most cases, a generic drug will be available. The Medications are classified on the Preferred Drug List Preferred (PDL) as Preferred, Non-Preferred or Non-PDL.
Members can call Member and Recipient Services at 1-877-685-2415 for printed version of the drug formulary to be mailed to them or to ask questions.
PerformRx updated the searchable formulary below each day. You can search the formulary for prescription limits, medications requiring prior authorization, and more:
Member Pharmacy Portal
Members can view their pharmacy benefits and coverage information. This website is separate from Trillium and you will need to provide your Medicaid Member ID in order to register to use the website.
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 you qualify for this program, Trillium will only covered for your pain medications and nerve medications when:
- Your medications are ordered by one prescriber. You will be given a chance to pick a prescriber in the Trillium network.
- You have these prescriptions filled from one pharmacy. You will be given a chance to pick a pharmacy in Trillium’s network.
If you qualify for the Trillium Lock-In Program, you will be in the program for a two-year period. 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 (see the 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.