Immunomodulator PA Requests
The recommended method for submitting a Prior Approval (PA) request is to key it directly into the secure NCTracks Provider Portal. Requesting medications via the portal is the fastest and most efficient method for obtaining prior approval.
To enter a PA for an Immunomodulator on the portal, complete the PA for Immunomodulators and add the appropriate Attachment below as an upload.
If you must mail or fax a Prior Approval request, use the appropriate form from below.
Note that the Immunomodulator PA request Attachments are identified by the disease state.
Updated Jan. 2, 2025
Immunomodulator PA Forms
- PA Form- Actemra (PDF, 477 KB)
- PA Form- Humira (PDF, 491 KB)
- PA Form- Avsola (PDF, 486 KB)
- PA Form- Cimzia (PDF, 486 KB)
- PA Form- Cosentyx (PDF, 481 KB)
- PA Form- Ilaris (PDF, 482 KB)
- PA Form- Ilumya (PDF, 466 KB)
- PA Form- Inflectra (PDF, 485 KB)
- PA Form- Kevzara (PDF, 465 KB)
- PA Form- Kineret (PDF, 472 KB)
- PA Form- Olumiant (PDF, 465 KB)
- PA Form- Otezla (PDF, 474 KB)
- PA Form- Remicade and Infliximab (PDF, 486 KB)
- PA Form- Stelara (PDF, 481 KB)
- PA Form- Siliq (PDF, 466 KB)
- PA Form- Renflexis (PDF, 486 KB)
- PA Form- Taltz (PDF, 477 KB)
- PA Form- Simponi (PDF, 473 KB)
- PA Form- Rinvoq ER (PDF, 467 KB)
- PA Form- Enbrel (PDF, 482 KB)
- PA Form- Enspryng (PDF, 463 KB)
- PA Form- Entyvio (PDF, 468 KB)
- PA Form- Simponi Aria (PDF, 475 KB)
- PA Form- Stelara Infusion (PDF, 467 KB)
- PA Form- Tremfya (PDF, 469 KB)
- PA Form- Xeljanz (PDF, 484 KB)
- PA Form- Xeljanz XR (PDF, 477 KB)
- PA Form- Arcalyst (PDF, 469 KB)
- PA Form- Uplinza (PDF, 464 KB)