Pharmacy Prior Authorization
Please Note: Pharmacy Benefits will start for Tailored Plan Medicaid members in
July 1, 2024.
Prior approval (PA) is required for certain drugs prescribed to NC Medicaid Tailored Plan recipients. Refer to the Prior Approval Criteria for specific drug criteria. Providers should attach any supporting documentation when required.
Prior Authorization Forms
- A+KIDS
- ADUHELM
- AMONDYS45
- Antinarcolepsy - Provigil, modafanil (Generic)
- Antinarcolepsy - Sinosi
- Antinarcolepsy - WAKIX
- ASAP
- BENLYSTA
- Camzyos
- CIALIS
- Continuous Glucose Monitors
- CRINONE
- Dupixent for Asthma
- Dupixent for Atopic Dermatitis
- Dupixent for Nasal Polyps
- EMEND-Aprepitant
- EMFLAZA
- EPIDIOLEX
- Epinephrine Pens
- EVRYSDI
- EXONDYS 51
- GATTEX
- GLP-1 Receptor Agonists and Combinations
- GOCOVRI and OSMOLEX ER
- Growth Hormone (Adult)
- Growth Hormone (Child)
- Hereditary Angioedema (HAE) Agents
- HETLIOZ, HETLIOZ LQ
- JUXTAPID
- Leqembi
- LUPKYNIS
- Migraine Calcitonin Agents (Preventative)(AIMOVIG, AJOVY, EMGALITY, VYEPTI, QULIPTA, NURTEC)
- Migraine Calcitonin Agents (ACUTE) (UBRELVY, NURTEC)
- Monoclonal Anibodies (FASENRA)
- Monoclonal Antibodies - Adbry
- Monoclonal Antibodies - Dupixent for Eosinophilic Esophagitis
- Monoclonal Antibodies - Dupixent for Prurigo Nodularis
- Monoclonal Antibodies (NUCALA)
- Monocolonal Antibodies (XOLAIR)
- Movement Disorder (INGREZZAJ)
- Movement Disorder (XENAZINE, tetrabenzine (generic))
- Movement Disorders (AUSTEDO)
- Neuromuscular Blocking Agents (BOTOX, MYOBLOC, DYSPORT, XEOMIN)
- NEXLETOL, NEXLIZET
- Non-Covered State Plan Services Request Form 21 under (Trillium) EPSDT FORM
- NUVGIIL_armodafinil
- Opioid Dependence
- PCSK9 Inhibitors - Praluent, Repatha
- PROCRIT- EPOGEN - ARANESP - MIRCERA - RETACRIT - REBLOZVL
- RELISTOR
- SAPHNELO
- Sedative Hypnotics
- SGLT2 Inhibitors and Combinations
- Standard Drug Request Form
- STROMECTOL - ivermectin
- SYNAGIS
- Tezspire
- Topical Antihistamines
- Topical Anti-inflammatories
- Topical Local Anesthetics
- Triptans
- Vivjoa
- Vowst
- Vusion
- Vyondys 53 and Viltepso
- Xolair for Nasal Polyps
- XYREM and XYWAV
- ZOLGENSMA
- Adult Onset Stills Disease
- Ankylosing Spondylitis
- Crohn's Disease (Adult)
- Crohn's Disease (Pediatric)
- Cryopyrin-Associated Periodic Syndromes Inc. Familial Cold Autoinflammatory Syndrome & Muckle-Wells Syndrome
- Cytokine Release Syndrome
- Deficiency of lnterleukin-1 Receptor Antagonist (DIRA)
- Familial Mediterranean Fever (FMF)
- Giant Cell Arteritis
- Hidradenitis Suppurativa
- Hyperimmunoglobulin D Syndrome (HIDS)-Mevalonate Kinase Deficiency (MKD)
- Neonatal Onset Multisystem Inflammatory Disease (NOMID)
- Neuromyelitis Optica Spectrum Disorder (NMOSD
- Non-infectious Intermediate Posterior Panuveitis
- Non-radiographic Axial Spondyloarthritis
- Oral Ulcers Associated with Behcets Disease
- Plaque Psoriasis (Adult)
- Plaque Psoriasis (Pediatric)
- Polyarticular Juvenile Idiopathic Arthritis (PJIA)
- Psoriatic Arthritis
- Rheumatoid Arthritis
- Systemic Onset Juvenile Idiopathic Arthritis (SJIA)
- Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS)
- Ulcerative Colitis (Adults)
- Ulcerative Colitis (Pediatric)
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