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 (Provigil and Nuvigil) (PDF, 492 KB)
- Antinarcolepsy (Sunosi) (PDF, 495 KB)
- Antinarcolepsy (Wakix) (PDF, 472 KB)
- Austedo for Movement Disorders (PDF, 465 KB)
- Chloroquine and Hydroxychloroquine Temporary PA Form (PDF, 462 KB)
- Cialis (PDF, 459 KB)
- Continuous Glucose Monitors (PDF, 536 KB)
- Crinone (PDF, 469 KB)
- Cystic Fibrosis (PDF, 567 KB)
- Dupixent for Asthma (PDF, 494 KB)
- Dupixent for Atopic Dermatitis (PDF, 493 KB)
- Dupixent for Nasal Polyps (PDF, 462 KB)
- Emend (PDF, 460 KB)
- Emflaza (PDF, 467 KB)
- Entresto (PDF, 465 KB)
- Epidiolex (PDF, 533 KB)
- Epinephrine Pens (PDF, 433 KB)
- Evrysdi (PDF, 531 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 or Kynamro (PDF, 532 KB)
- Lupus Medications (PDF, 429 KB)
- Migraine Calcitonin Gene Related Therapy (PDF, 447 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, 458 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, 530 KB)
- Zolgensma (PDF, 556 KB)
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