North Carolina Medicaid Prior Authorization Form

PDF
PDF

Updated January 23, 2022

A North Carolina Medicaid prior authorization form is a document used by North Carolina-based medical professionals to request Medicaid coverage for a non-preferred drug. On the form, the person making the request must provide the medical justification for not prescribing a drug from the Preferred Drug List. The PA Call Center can provide more information about specific situations at the phone number provided below.

Fax – 1 (855) 710-1969

Phone – 1 (866) 246-8505

Preferred Drug List

How to Write

Step 1 – Download the PDF version of the form here and open it with Adobe Acrobat or Microsoft Word.

Step 2 – Begin filling out the form by entering the recipient’s full name, ID number, date of birth, and gender.

Step 3 – Next, use the checkboxes to indicate that this is a Medicaid request.

Step 4 – In the “Prescriber Information” section, you will need to provide the following information:

  • Prescribing provider ID number (select either NPI or Atypical)
  • Prescriber DEA number
  • Requester’s name
  • Requester’s phone number

Step 5 – Beneath “Drug Information,” enter the name and indicate whether this is a request for a non-preferred drug or not. Then, enter the strength, quantity per 30 days, and the estimated length of therapy for this prescription.

Step 6 –  In the “Medical History” section, you will need to check the box next to each applicable situation listed below and provide the requisite information in the appropriate field.

  • One or two preferred drug(s) failed in treatment of diagnoses (list the drugs and describe the patient’s reaction)
  • Patient has had an unacceptable side effect or therapeutic failure (provide clinical information)
  • There is a clinical contraindication, co-morbidity, or unique patient circumstance as a contraindication to preferred drug(s) (provide clinical information)
  • There are age specific indications to this case (give patient age and explain the situation)
  • There is a clinical indication that is FDA-supported or peer reviewed literature (explain and provide a general reference)
  • There is an unacceptable clinical risk associated with therapeutic change (explain)

Step 7 – Provide the prescriber’s signature and the date.

Step 8 – Fax the completed form to the correct directory.