Drug Request Forms
Prior approval (PA) is required for certain drugs prescribed to NC Medicaid 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.
- A+KIDS (Antipsychotics-Keeping it Documented for Safety) (PDF, 557 KB)
- Aduhelm Injection (2022, 550 KB)
- Amondys 45 (PDF, 533 KB)
- 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 Xywav) (VND.OPENXMLFORMATS-OFFICEDOCUMENT.WORDPROCESSINGML.DOCUMENT, 29 KB)
- Antiparkinsons Agents (Inbrija and Ongentyx) (PDF, 637 KB)
- Austedo for Movement Disorders (PDF, 470 KB)
- ASAP (Atypical Antipsychotics) (PDF, 562 KB)
- Camzyos (2024, 480 KB)
- Cialis (PDF, 459 KB)
- Continuous Glucose Monitors (PDF, 551 KB)
- Crinone (PDF, 471 KB)
- Cystic Fibrosis (PDF, 471 KB)
- Dupixent for Asthma (PDF, 142 KB)
- Duchenne Muscular Dystrophy (Vyondys 53 and Viltepso) (PDF, 614 KB)
- Dupixent for Atopic Dermatitis (19, 135 KB)
- Dupixent for Eosinophilic Esophagitis (PDF, 133 KB)
- Dupixent for Nasal Polyps (PDF, 134 KB)
- Dupixent for Prurigo Nodularis (PDF, 239 KB)
- Emflaza (PDF, 454 KB)
- Epidiolex (PDF, 36 KB)
- Epinephrine Pens (PDF, 216 KB)
- Evrysdi (PDF, 546 KB)
- Exondys 51 (PDF, 531 KB)
- Fasenra (PDF, 467 KB)
- Gattex (PDF, 427 KB)
- GLP-1 Receptor Agonists and Combinations (PDF, 469 KB)
- GLP-1s for Weight Management (PDF, 642 KB)
- Gocovri and Osmolex ER (PDF, 430 KB)
- Growth Hormone (Adult) (PDF, 628 KB)
- Growth Hormone (Child) (PDF, 630 KB)
- Hematinics (PDF, 432 KB)
- Hepatitis C
- Hereditary Angioedema (HAE) Agents (2024, 484 KB)
- Hetlioz (PDF, 432 KB)
- Hormone Therapy for Beneficiaries Under 18 (PDF, 472 KB)
- Immunomodulators
- Ingrezza for Movement Disorders (PDF, 461 KB)
- Ivermectin (PDF, 425 KB)
- Juxtapid (PDF, 532 KB)
- Leqembi (PDF, 284 KB)
- Lupus (Benlysta) (PDF, 428 KB)
- Lupus (Lupykinis) (PDF, 545 KB)
- Lupus (Saphnelo) (PDF, 434 KB)
- Migraine Calcitonin Gene Related Therapy (Preventative) (PDF, 224 KB)
- Migraine Calcitonin Agents (Ubrelvy Nurtec) (Acute) (PDF, 211 KB)
- Monoclonal Antibodies (Adbry) (2024, 248 KB)
- Neuromuscular Blocking Agents (PDF, 566 KB)
- Nexlizet and Nexletol (PDF, 446 KB)
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old (PDF, 220 KB)
- Nucala (PDF, 457 KB)
- Opioid Analgesics (Short and Long-Acting)
- Opioid Dependence Therapy Agents (PDF, 463 KB)
- PCSK9 Inhibitors (PDF, 466 KB)
- Sedative Hypnotics (PDF, 459 KB)
- Selective Constipation Agents (Relistor) (PDF, 463 KB)
- SGLT2 Inhibitors and Combinations (PDF, 473 KB)
- Standard Drug Request Form (PDF, 428 KB)
- PA Form - Synagis 2024 (PDF, 463 KB)
- Tezspire (PDF, 253 KB)
- Topical Antihistamines (PDF, 461 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, 642 KB)
- Xenazine and tetrabenazine for Movement Disorders (PDF, 465 KB)
- Xolair (PDF, 622 KB)
- Xolair for Nasal Polyps (PDF, 510 KB)
- Vivjoa (PDF, 469 KB)
- Vowst (PDF, 577 KB)
- Zolgensma (PDF, 554 KB)
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