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.
- Celebrex (celecoxib) (PDF, 358 KB)
- Cialis (PDF, 275 KB)
- Cystic Fibrosis (Kalydeco and Orkambi) (PDF, 387 KB)
- Crinone 8% Gel (PDF, 267 KB)
- Emend (PDF, 352 KB)
- Epinephrine Pens (PDF, 287 KB)
- Growth Hormone – Adult (PDF, 304 KB)
- Growth Hormone – Child (PDF, 302 KB)
- Hematinics (Procrit, Epogen, Aranesp) (PDF, 271 KB)
- Hepatitis C
- Immunomodulators - PA Request Forms
- Juxtapid or Kynamro (PDF, 314 KB)
- Topical Local Anesthetics (Lidoderm Patch, lidocaine patch, and ZT Lido) (PDF, 189 KB)
- Neuromuscular Blocking Agents (PDF, 284 KB)
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old (PDF, 270 KB)
- Opioid Analgesics (Short and Long-Acting)
- Provigil (PDF, 277 KB)
- Sedative Hypnotics (PDF, 245 KB)
- Standard Drug Request Form (PDF, 290 KB)
- Topical Anti-Inflammatory (PDF, 189 KB)
- Triptans (PDF, 401 KB)
- Vusion (PDF, 277 KB)
- Xolair (PDF, 355 KB)
Temporary PA Request Forms
For drugs that have not yet been added to the PA request screens on the secure NCTracks provider portal, providers can fax or mail a PA request to CSRA at (855) 710-1969 or CSRA PO Box 300009
Raleigh, NC 27622-8009, using a temporary form. The temporary PA request forms are listed below in alphabetical order.
Austedo for Movement Disorders
Dupixent for Atopic Dermatitis
Ingrezza for Movement Disorders
Migraine Calcitonin Gene Related Therapy
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