Pharmacy Prior Authorization
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
- Antiparkinson’s: Inbrija and Ongentys
- ASAP
- BENLYSTA
- Camzyos
- CIALIS
- Continuous Glucose Monitors
- CRINONE
- Cystic Fibrosis: Kalydeco, Orkambi, Symdeko, and Trikafta
- 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
- GLP-1 for Weight Management
- GOCOVRI and OSMOLEX ER
- Growth Hormone (Adult)
- Growth Hormone (Child)
- Hereditary Angioedema (HAE) Agents
- HETLIOZ, HETLIOZ LQ
- Hormonal Products for Beneficiaries Under 18 Years of Age
- 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
- 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
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