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.
Review Clinical Coverage Policy 1S-13 Cell & Gene Therapies prior to submitting a prior approval (PA).
DO NOT use a Drug Request Form to submit prior approval (PA) for Cell & Gene Therapies. Use the NCTracks Secure Provider Portal to submit a Medical PA for Cell & Gene Therapies using PA Type TRANSPLANT. Use the most appropriate procedure code for the specific Cell & Gene Therapy you are requesting. Attach any supporting documentation when required.
If the request is for a Cell & Gene Therapy that is provided outside the state of North Carolina, please review Clinical Coverage Policy 2A-3 Out-of-State Services prior to submitting PA. Use the NCTracks Secure Provider Portal to submit an OUT OF STA (OUT OF STATE) PA for Cell & Gene Therapies. Attach any supporting documentation when required.
PA criteria for individual cell and gene therapies will be posted here.
BH Clinical Edit Resolution: Submission Clarification Code 10
Bypassing the edit will require an override (SCC 10) that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue alerted by the edit.
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NCTracks