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A+KIDS: Antipsychotics - Keeping it Documented for Safety [17 Years of Age and Younger] (North Carolina) Prior Authorization Form - Community Plan
Last Published 10.25.2021
Abilify Maintena, Aristada, Aristada Initio, Haldol decanoate, haloperidol decanoate, Invega Sustenna, Invega Trinza, Perseris, Risperdal Consta, Zyprexa Relprevv, aripiprazole, clozapine, Latuda, olanzapine, Zyprexa, olanzapine ODT, paliperidone ER, quetiapine, quetiapine ER, risperidone, risperidone ODT, Saphris, asenapine, Symbyax, ziprasidone, Abilify, Abilify MyCite, aripiprazole ODT, Caplyta, clozapine ODT, Clozaril, Fanapt, Fanapt Titration pack, Geodon, Invega, Nuplazid, olanzapine/fluoxetine, Rexulti, Risperdal, Secuado, Seroquel, Seroquel XR, Versacloz, Vraylar, Zyprexa, Zyprexa Zydis, haloperidol, loxapine, chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, thioridazine, trifluoperazine, thiothixene, perphenazine/amitriptyline ,
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Adbry (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Adbry,
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Aduhelm (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Aduhelm,
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Amondys 45 (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.23.2023
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Anti-narcolepsy [Armodafinil, Modafinil, Nuvigil, Provigil] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.13.2023
"Provigil, Nuvigil, Armodafinil, Modafinil ",
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Anti-narcolepsy [Sunosi] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Sunosi ,
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Anti-narcolepsy [Wakix] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Wakix,
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Anti-narcolepsy [Xyrem] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.14.2022
Xyrem,
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Anti-narcolepsy [Xywav] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.14.2022
Xywav,
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Anti-parkinson's Agents [Inbrija, Ongentyx] (North Carolina) Prior Authorization Form - Community Plan
Last Published 10.01.2021
"Inbrija, Ongentyx",
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Anti-parkinson’s Agents [Gocovri, Osmolex ER] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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ASAP: Adult Safety with Antipsychotic Prescribing [18 Years of Age and Older] (North Carolina) Prior Authorization Form - Community Plan
Last Published 10.25.2021
Abilify Maintena, Aristada, Aristada Initio, Haldol decanoate, haloperidol decanoate, Invega Sustenna, Invega Trinza, Perseris, Risperdal Consta, Zyprexa Relprevv, aripiprazole, clozapine, Latuda, olanzapine, Zyprexa, olanzapine ODT, paliperidone ER, quetiapine, quetiapine ER, risperidone, risperidone ODT, Saphris, asenapine, Symbyax, ziprasidone, Abilify, Abilify MyCite, aripiprazole ODT, Caplyta, clozapine ODT, Clozaril, Fanapt, Fanapt Titration pack, Geodon, Invega, Nuplazid, olanzapine/fluoxetine, Rexulti, Risperdal, Secuado, Seroquel, Seroquel XR, Versacloz, Vraylar, Zyprexa, Zyprexa Zydis, haloperidol, loxapine, chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, thioridazine, trifluoperazine, thiothixene, perphenazine/amitriptyline ,
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Austedo (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Austedo,
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Camzyos (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Camzyos,
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Continuous Glucose Monitors (North Carolina) Prior Authorization Form - Community Plan
Last Published 08.01.2024
"Dexcom, FreeStyle Libre",
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Crinone (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Crinone ,
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Cystic Fibrosis [Kalydeco, Orkambi, Symdeko, Trikafta] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Kalydeco, Orkambi, Symdeko, Trikafta,
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Dupixent - Asthma (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Dupixent,
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Dupixent - Atopic Dermatitis (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Dupixent,
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Dupixent - Eosinophilic Esophagitis (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Dupixent,
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Dupixent - Nasal Polyps (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Dupixent,
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Dupixent - Prurigo Nodularis (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Dupixent,
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Emend (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.02.2023
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Emflaza (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.13.2023
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Entresto (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Epclusa (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Epidiolex (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Epidiolex,
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Epinephrine Products (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"EpiPen, epinephrine, Auvi-Q, Symjepi",
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Evrysdi (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Exondys 51 (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Fasenra (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Gattex (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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GLP-1 for Weight Management (North Carolina) Prior Authorization Form - Community Plan
Last Published 08.01.2024
"Wegovy, Saxenda, Zepbound",
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GLP-1 Receptor Agonists and Combinations (North Carolina) Prior Authorization Form - Community Plan
Last Published 08.01.2024
"Byetta, Trulicity, Victoza, Ozempic, Adlyxin, Bydureon Bcise, Rybelsus, Soliqua, Xultophy, Mounjaro ",
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Growth Hormone [Adult] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Humatrope, Nutropin AQ Nuspin, Omnitrope, Saizen, Zomacton, Genotropin, Genotropin MiniQuick, Norditropin Flexpro, Serostim ,
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Growth Hormone [Child] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Humatrope, Nutropin AQ Nuspin, Omnitrope, Saizen, Zomacton, Genotropin, Genotropin MiniQuick, Norditropin Flexpro, Serostim ,
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Harvoni (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Hematinics (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Procrit, Epogen, Aranesp, Mircera, Retacrit, Reblozyl ",
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Hereditary Angioedema (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Cinryze, Haegarda, Orladeyo, Takhzyro, Berinert, Firazyr, icatibant, Sajazir, Kalbitor, Ruconest",
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Hetlioz, Hetlioz LQ (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Hormonal Products for Beneficiaries under 18 years of age (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.14.2024
"Camcevi, Eligard, Fensolvi, Leuprolide, Lupron Depot, Supprelin LA, Trelstar, Triptodur, Zoladex",
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Immunomodulators: Ankylosing Spondylitis (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Enbrel, Humira, Cosentyx, Avsola, Inflectra, Cimzia, Simponi, Simponi Aria, Remicade, Renflexis, Taltz,
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Immunomodulators: Crohn's disease [Adult] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Humira, Avsola, Cimzia, Entyvio, Inflectra, Stelara, Stelara Infusion, Remicade, Renflexis,
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Immunomodulators: Crohn's disease [Pediatric] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Humira, Avsola, Inflectra, Remicade, Renflexis,
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Immunomodulators: Cryopyrin-Associated Periodic Syndromes (CAPS), Familial Cold Autoinflammatory Syndrome (FCAS), Muckle-Wells Syndrome (MWS) [Arcalyst and Ilaris] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Arcalyst, Ilaris,
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Immunomodulators: Cytokine Release Syndrome [Actemra] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.02.2021
Actemra,
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Immunomodulators: Deficiency of Interleukin-1 Receptor Antagonist (DIRA) [Arcalyst and Kineret] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Arcalyst, Kineret,
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Immunomodulators: Familial Mediterranean Fever [Ilaris] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Ilaris,
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Immunomodulators: Giant Cell Arteritis [Actemra] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Actemra,
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Immunomodulators: Hidradenitis Suppurativa [Humira] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Humira,
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Immunomodulators: Hyperimmunoglobulin D Syndrome (HIDS), Mevalonate Kinase Deficiency (MKD) [Ilaris] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Ilaris,
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Immunomodulators: Neonatal Onset Multisystem Inflammatory Disease (NOMID) [Kineret] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Kineret,
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Immunomodulators: Neuromyelitis Optica Spectrum Disorder [Uplizna, Enspryng] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Uplizna, Enspryng,
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Immunomodulators: Non-Infectious Intermediate Posterior Panuveitis [Humira] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Humira,
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Immunomodulators: Non-Radiographic Axial Spondyloarthritis [Cimzia, Cosentyx, Taltz] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Cimzia, Cosentyx, Taltz,
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Immunomodulators: Oral Ulcers associated with Behcet's disease [Otezla] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Otezla,
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Immunomodulators: Plaque Psoriasis [Adult] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.17.2022
Enbrel, Humira, Cosentyx, Avsola, Cimzia, Ilumya, Inflectra, Otezla, Remicade, Renflexis, Siliq, Skyrizi, Stelara, Taltz, Tremfya,
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Immunomodulators: Plaque Psoriasis [Pediatric] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Enbrel, Stelara, Taltz,
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Immunomodulators: Polyarticular Juvenile Idiopathic Arthritis [PJIA] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Enbrel, Humira, Actemra SQ, Actemra Infusion, Simponi Aria, Orencia SQ, Orencia Infusion, Xeljanz,
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Immunomodulators: Psoriatic Arthritis (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Enbrel, Humira, Cosentyx, Avsola, Cimzia, Inflectra, Orencia SQ, Orencia Infusion, Otezla, Remicade, Renflexis, Simponi, Simponi Aria, Stelara, Taltz, Tremfya, Xeljanz, Xeljanz XR,
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Immunomodulators: Rheumatoid Arthritis (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Enbrel, Humira, Actemra, Avsola, Cimzia, Inflectra, Kevzara, Kineret, Olumiant, Orencia, Remicade, Renflexis, Rinvoq ER, Simponi, Simponi Aria, Xeljanz, Xeljanz XR,
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Immunomodulators: Still's Disease [Ilaris] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Ilaris,
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Immunomodulators: Systemic Onset Juvenile Idiopathic Arthritis [SJIA] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Actemra, Ilaris,
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Immunomodulators: Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) [Ilaris] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Ilaris,
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Immunomodulators: Ulcerative Colitis (Pediatric) [Remicade] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Remicade,
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Immunomodulators: Ulcerative Colitis [Adult] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Humira, Avsola, Entyvio, Inflectra, Remicade, Renflexis, Stelara, Simponi, Xeljanz, Xeljanz XR,
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Ingrezza (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Juxtapid, Kynamro (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Leqembi (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Leqembi,
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Long-Acting Opioid Analgesic (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Belbuca, buprenorphine patch, Conzip, Duragesic, fentanyl patch, hydrocodone ER, hydromorphone ER, hydrocodone ER, Hysingla, morphine ER, MS Contin, Nucynta ER, oxycodone ER, Oxycontin, oxymorphone ER, Zohydro ER, Butrans, tramadol ER, Xtampza, methadone, Methadose ,
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Lupus [Benlysta] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Lupus [Lupkynis] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Lupus [Saphnelo] (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.23.2023
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Mavyret (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Migraine - Calcitonin Agents: Acute Treatment (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Ubrelvy, Nurtec",
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Migraine - Calcitonin Agents: Preventative (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Aimovig, Ajovy, Emgality, Vyepti, Qulipta, Nurtec",
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Neuromuscular Blocking Agents [Botox, Myobloc, Dysport, Xeomin] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Nexletol, Nexlizet (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.23.2023
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Non-Covered State Medicaid Plan Services (North Carolina) Request Form for Recipients under 21 Years Old - Community Plan
Last Published 11.17.2022
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North Carolina Pharmacy Prior Approval Request form
Last Published 07.21.2023
North Carolina Pharmacy Prior Approval Request for Standard Drug Request Form,
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Nucala (North Carolina) Prior Authorization Form - Community Plan
Last Published 01.30.2023
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Opioid Dependence (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Suboxone, Sublocade, buprenorphine/naloxone, Zubsolv, Lucemyra, buprenorphine",
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PCSK9 Inhibitors [Praluent, Repatha] (North Carolina) Prior Authorization Form - Community Plan
Last Published 01.30.2023
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Sedative-Hypnotics (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Ambien, Ambien CR, Belsomra, Dayvigo, doxepin, Edluar, estazolam, eszopiclone, Halcion, Lunesta, ramelteon, Restoril, Rozerem, Silenor, temazepam, triazolam, zaleplon, zolpidem ER, generic zolpidem SL,
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Selective Constipation Agents [Relistor] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.17.2023
,
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SGLT2 Inhibitor and Combinations (North Carolina) Prior Authorization Form - Community Plan
Last Published 06.18.2024
"Farxiga, Jardiance, Invokamet, Invokamet XR, Invokana, Segluromet, Steglatro, Synjardy, Synjardy XR, Xigduo XR, dapagliflozin, dapagliflozin/metformin ",
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Short-Acting Opioid Analgesic (North Carolina) Prior Authorization Form - Community Plan
Last Published 04.03.2023
Dsuvia, Fentora, Actiq, fentanyl citrate lozenge, Apadaz, benzhydrocodone/acetaminophen, codeine, Dilaudid, hydromorphone, levorphanol, Lortab, meperidine, morphine, Nalocet, Nucynta, Oxaydo, oxycodone/aspirin, oxycodone, oxymorphone, Percocet, Prolate, Roxicodone, Endocet, hydrocodone/acetaminophen, Xodol, hydrocodone/ibuprofen, oxycodone/acetaminophen, Ascomp/codeine, butalbital/aspirin/caffeine/codeine, butalbital/acetaminophen/caffeine/codeine, butorphanol nasal, acetaminophen/caffeine/dihydrocodeine, Fioricet/codeine, pentazocine/naloxone, Ultracet, Ultram, acetaminophen/codeine, tramadol, tramadol/acetaminophen, Lazanda, Opana, Subsys,
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Sofosbuvir-Velpatasvir (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Sovaldi (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Stromectol, Ivermectin (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Synagis (North Carolina) Prior Authorization Form - Community Plan
Last Published 10.31.2023
Synagis,
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Tezspire (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Tezspire,
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Topical Anesthetics [Lidoderm, Lidocaine patch, ZTLido] (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
"Lidoderm, lidocaine patch, ZTLido",
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Topical Anti-Inflammatories (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.14.2022
Elidel, pimecrolimus cream, Protopic 0.03%, tacrolimus 0.03%, Eucrisa, Protopic 0.1%, tacrolimus 0.1%, Opzelura,
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Topical Antifungal Agents [Vusion] (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Topical Antihistamines (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Prudoxin, Zonalon, doxepin cream ,
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Triptans (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.18.2022
Amerge, naratriptan, almotriptan, Frova, frovatriptan, Imitrex, sumatriptan, Maxalt, Maxalt-MLT, rizatriptan, rizatriptan ODT, Relpax, eletriptan, Treximet, sumatriptan/naproxen, Zomig, Zomig-ZMT, zolmitriptan, zolmitriptan ODT, Migranow Kit, Onzetra Xsail, Tosymra, Zembrace Symtouch, Zomig nasal spray, zolitriptan nasal spray ,
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Viekira (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Vivjoa (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Vivjoa,
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Vosevi (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Vowst (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Vowst,
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Vyondys 53, Viltepso (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Xenazine (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.17.2023
Xenazine, Tetrabenazine,
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Xolair: Allergic Asthma, Chronic Idiopathic Urticaria (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.17.2023
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Xolair: Nasal Polyps (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.17.2023
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Zepatier (North Carolina) Prior Authorization Form - Community Plan
Last Published 02.14.2022
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Zolgensma (North Carolina) Prior Authorization Form - Community Plan
Last Published 07.12.2024
Zolgensma ,