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 May 20, 2025

Immunomodulator PA Forms