NCTracks
Drug Request Forms
Prior approval (PA) is required for certain drugs prescribed to N.C. Medicaid and Health Choice recipients. Refer to the Prior Approval Drugs and Criteria page for specific criteria. Providers may submit requests via fax, phone or through the secure NCTracks secure provider portal.
The recommended method for submitting a 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. Providers should attach any supporting documentation when required.
- Antiemetic Agents (PDF, 460 KB)
- Antinarcolepsy (Provigil and Nuvigil) (PDF, 492 KB)
- Antinarcolepsy (Sunosi) (PDF, 496 KB)
- Antinarcolepsy (Wakix) (PDF, 472 KB)
- Antinarcolepsy (Xyrem and Xywaz) (PDF, 494 KB)
- Austedo for Movement Disorders (PDF, 466 KB)
- Cialis (PDF, 459 KB)
- Continuous Glucose Monitors (PDF, 536 KB)
- Crinone (PDF, 471 KB)
- Cystic Fibrosis (PDF, 470 KB)
- Dupixent for Asthma (PDF, 492 KB)
- Dupixent for Atopic Dermatitis (PDF, 466 KB)
- Dupixent for Nasal Polyps (PDF, 461 KB)
- Emflaza (PDF, 467 KB)
- Entresto (PDF, 465 KB)
- Epidiolex (PDF, 533 KB)
- Epinephrine Pens (PDF, 433 KB)
- Evrysdi (PDF, 546 KB)
- Exondys 51 (PDF, 531 KB)
- Fasenra (PDF, 467 KB)
- Gattex (PDF, 427 KB)
- Gocovri and Osmolex ER (PDF, 430 KB)
- Growth Hormone – Adult (PDF, 628 KB)
- Growth Hormone – Child (PDF, 630 KB)
- Hematinics (PDF, 430 KB)
- Hepatitis C
- Hetlioz (PDF, 431 KB)
- Immunomodulators - PA Request Forms
- Ingrezza for Movement Disorders (PDF, 461 KB)
- Juxtapid (PDF, 532 KB)
- Lupus Medications (PDF, 429 KB)
- Migraine Calcitonin Gene Related Therapy (PDF, 447 KB)
- Migraine Calcitonin Agents (Ubrelvy Nurtec) (PDF, 431 KB)
- Neuromuscular Blocking Agents (PDF, 566 KB)
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old (PDF, 220 KB)
- Nucala (DOCX, 449 KB)
- Opioid Analgesics (Short and Long-Acting)
- Opioid Dependence Therapy Agents (PDF, 463 KB)
- PCSK9 Inhibitors (PDF, 461 KB)
- Sedative Hypnotics (PDF, 459 KB)
- Selective Constipation Agents (Relistor) (PDF, 463 KB)
- Standard Drug Request Form (PDF, 428 KB)
- Topical Antihistamines (PDF, 462 KB)
- Topical Anti-Inflammatory (PDF, 461 KB)
- Topical Local Anesthetics (Lidoderm Patch, lidocaine patch, and ZT Lido) (PDF, 456 KB)
- Triptans (PDF, 458 KB)
- Vusion (PDF, 488 KB)
- Xenazine and tetrabenazine for Movement Disorders (PDF, 465 KB)
- Xolair (PDF, 622 KB)
- Zolgensma (PDF, 556 KB)
PDF documents on this page require the free Adobe Reader to view and print.