NCTracks
Immunomodulator PA Criteria Forms
Prior authorization (PA) is required for certain drugs prescribed to NC Medicaid recipients. Refer to the links below for specific criteria. Providers may submit requests for approval via fax, phone or via the NCTracks secure portal. The portal is the most efficient method for PA processing.
- Arcalyst (PDF, 200 KB)
- Actemra (PDF, 167 KB)
- Avsola (PDF, 307 KB)
- Cimzia (PDF, 304 KB)
- Cosentyx (PDF, 211 KB)
- Enbrel (PDF, 210 KB)
- Enspryng (PDF, 151 KB)
- Entyvio (PDF, 245 KB)
- Humira (PDF, 311 KB)
- Ilaris (PDF, 256 KB)
- Ilumya (PDF, 197 KB)
- Inflectra (PDF, 304 KB)
- Kevzara (PDF, 154 KB)
- Kineret (PDF, 156 KB)
- Olumiant (PDF, 154 KB)
- Orencia (PDF, 162 KB)
- Otezla (PDF, 296 KB)
- Remicade (PDF, 306 KB)
- Renflexis (PDF, 307 KB)
- Rinvoq (PDF, 158 KB)
- Siliq (PDF, 198 KB)
- Simponi (PDF, 159 KB)
- Simponi Aria (PDF, 163 KB)
- Skyrizi (PDF, 202 KB)
- Stelara (PDF, 302 KB)
- Stelara Infusion (PDF, 243 KB)
- Taltz (PDF, 212 KB)
- Tremfya (PDF, 201 KB)
- Uplinza (PDF, 152 KB)
- Xeljanz (PDF, 172 KB)
- Xeljanz XR (PDF, 168 KB)