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.
- Antinarcolepsy/Antihyperkinesis Agents (Provigil and Nuvigil) (PDF, 277 KB)
- Austedo for Movement Disorders (PDF, 138 KB)
- Chloroquine and Hydroxychloroquine Temporary PA Form (PDF, 452 KB)
- Cialis (PDF, 275 KB)
- Continuous Glucose Monitors (PDF, 125 KB)
- Crinone 8% Gel (PDF, 267 KB)
- Cystic Fibrosis (PDF, 532 KB)
- Dupixent for Asthma (PDF, 134 KB)
- Dupixent for Atopic Dermatitis (PDF, 186 KB)
- Dupixent for Nasal Polyps (PDF, 413 KB)
- Emend (PDF, 352 KB)
- Emflaza (PDF, 539 KB)
- Entresto (PDF, 190 KB)
- Epinephrine Pens (PDF, 287 KB)
- Evrysdi (PDF, 131 KB)
- Exondys 51 (PDF, 387 KB)
- Fasenra (PDF, 83 KB)
- Gattex (PDF, 189 KB)
- Gocovri and Osmolex ER (PDF, 127 KB)
- Growth Hormone – Adult (PDF, 304 KB)
- Growth Hormone – Child (PDF, 302 KB)
- Hematinics (PDF, 526 KB)
- Hepatitis C
- Immunomodulators - PA Request Forms
- Ingrezza for Movement Disorders (PDF, 24 KB)
- Juxtapid or Kynamro (PDF, 314 KB)
- Lupus Medications (PDF, 104 KB)
- Migraine Calcitonin Gene Related Therapy (PDF, 31 KB)
- Neuromuscular Blocking Agents (PDF, 284 KB)
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old (PDF, 220 KB)
- Non-Steroidal Anti-Inflammatory Drugs including Cox-2 Inhibitors. (PDF, 358 KB)
- Nucala (DOCX, 85 KB)
- Opioid Analgesics (Short and Long-Acting)
- Opioid Dependence Therapy Agents (PDF, 386 KB)
- Sedative Hypnotics (PDF, 229 KB)
- Selective Constipation Agents (Relistor) (PDF, 191 KB)
- Standard Drug Request Form (PDF, 290 KB)
- Topical Antihistamines (PDF, 192 KB)
- Topical Anti-Inflammatory (PDF, 189 KB)
- Topical Local Anesthetics (Lidoderm Patch, lidocaine patch, and ZT Lido) (PDF, 189 KB)
- Triptans (PDF, 401 KB)
- Vusion (PDF, 298 KB)
- Xenazine and tetrabenazine for Movement Disorders (PDF, 83 KB)
- Xolair (PDF, 355 KB)
- Zolgensma PA Form (PDF, 127 KB)
PDF documents on this page require the free Adobe Reader to view and print.