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.

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.

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