Prior Authorization for Prescription Drugs

Prior authorization is required for certain drugs prescribed to North Carolina Medicaid recipients. Each drug that is on the prior authorization list is monitored to determine the effect of the prior authorization process on utilization and appropriate use.

Prior Authorization Criteria for Medications Covered by Medicaid
Prior Authorization Forms for Medications Covered by Medicaid
Prior Authorization for Outpatient Pharmacy Point of Sale Medications, General Clinical Coverage Policy #A3
Please see the What's New page on the Enhanced Pharmacy Program website for updates to prior authorization criteria.

Drugs that Require Prior Authorization

Drug Class	PA Not Required Prescription Advantage List - Tier 1 Drugs	PA Required	Policy
Allergic Rhinitis and Asthma
Second Generation Antihistamines	Loratidine OTC Claritin OTC Cetirizine OTC Zyrtec OTC	Allegra Clarinex Xyzal Zyrtec Fexofenadine Cetirizine	Prior Authorization Criteria
Nasal Anti-inflammatory Steroids	Generic: flunisolide fluticasone	Beconase AQ Flonase Nasacort AQ Nasarel Nasonex Omnaris Rhinocort Aqua Vermyst	Prior authorization is NOT required for patients under 4 years of age Prior Authorization Criteria
Anemia
Hematinics	Generic preparations are not available	Aranesp Epogen Procrit	Prior Authorization Criteria
Asthma
Short Acting Beta Agonists	Proventil HFA Ventolin HFA Generic: albuterol	Accuneb Inhaled Solution Alupent Inhaler Maxair Auto-inhaler Proair HFA Relion Ventolin HFA Xopenex Inhaled Solution	Prior Authorization Criteria
Cholesterol Control
Lipotropics	Generic: gemfibrozil	Antara Fenoglide Lipofen Lofibra Lopid Tricor Triglide Trilipix Lovaza (Omacor) generic fenofibrate	Prior Authorization Criteria
Convulsions
Anticonvulsants	Generic preparations are available	Lamictal Lamictal ODT Lamictal XR Lyrica Topamax Trileptal	Prior Authorization Criteria
Daytime Sleepiness
Antinarcolepsy/ Antihyperkinesis Agents	Generic preparations are not available	Nuvigil Provigil	Prior Authorization Criteria
Gastrointestinal Disorders
Proton Pump Inhibitors	Prilosec OTC Generic: omeprazole, 20mg or 40mg	Aciphex Kapidex Nexium Protonix Prevacid Prilosec Pantoprazole	Prior Authorization Criteria
Hormone Deficiency
Growth Hormones	Generic preparations are not available	Genotropin Gentropin Miniquick products Humatrope Norditropin Nordiflex Nutropin Nutropin Depot Nutropin AQ Omnitrope Saizen Tev-Tropin Zorbtive Increlex	Prior Authorization Criteria
Hypertension
ACE Inhibitors	Generic: benazepril captopril enalapril fosinopril lisinopril moexipril ramiprilquinapril trandolapril	Accupril Aceon Altace Capoten Lotensin Mavik Monopril Prinvil Univasc Vasotec Zestril	Prior Authorization Criteria
Angiotensin Receptor Blockers	Generic preparations are not available	Atacand Avapro Benicar Cozaar Diovan Micardis Teveten	Prior Authorization Criteria
Renin Inhibitor	Generic preparations are not available	Tekturna	Prior Authorization Criteria
Combination Products	Generic: amlodipine and benazepril benazepril and HCTZ captorpril and HCTZ enalapril and HCTZ fosinopril and HCTZ lisinopril and HCTZ moexipril and HCTZ quinapril and HCTZ	Atacand HCT Avalide Azor Benicar HCT Diovan HCT Exforge Exforge HCT Hyzaar Micardis HCT Teveten HCT Accuretic Capozide Lexxel Lotensin HCT Lotrel Monopril HCT Prinzide Quinaretic Tarka Uniretic Vaseretic Zestoretic Teckturna HCT	Prior Authorization Criteria
Insomnia
Hypnotics, Non-benzodiazepines	Generic preparations available	Ambien Ambien CR Sonata Lunesta Rozerem Edluar Zolpidem Zaleplon	Generic and brand name quantities greater than 15 units per calendar month require prior authorization Prior Authorization Criteria
Benzodiazepine	Generic preparations available	ProSom Dalmane Halicon Doral Restoril Estazolam Flurazepam Triazolam Temazepam	Generic and brand name quantities greater than 15 units per calendar month require prior authorization Prior Authorization Criteria
Malaria
Antimalarial Drugs	Generic preparations are not available	Qualaquin	Prior Authorization Criteria
Migraines
Antimigraine Agents	Generic preparations available	Amerge Axert Frova Imitrex Maxalt Maxalt MLT Relpax Treximet Zomig Zomig MLT Sumatriptan	Generic and brand name quantities greater than 12 units per calendar month require prior authorization Prior Authorization Criteria
Neuromuscular Disorders
Neuromuscular Blocking Agents	Generic preparations are not available	Botox Myobloc	Prior Authorization Criteria
Pain
CII Narcotic Analgesics Short-acting	Generic: fentanyl oxycodone and ibuprofen meperidine hydromorphone levophanol oxycodone and APAP oxycodone	Actiq Combunox Demerol Dilaudid Endodan Fentora Levo-Drocoran Magnacet Opana Oxy-IR Percocet Percodan Roxicodone Tylox Xolox Nucynta Lynox	Prior Authorization Criteria
CII Narcotic Analgesics Long-acting	Generic: morphine sulfate fentanyl methadone oxycodone	Avinza Duragesic Kadian SR MS Contin Opan ER Oxycontin Oramorph SR Dolophine Methadose	Prior Authorization Criteria
NSAID	Generic preparations are not available	Celebrex	Prior authorization is NOT required for patients 60 years of age and older Prior Authorization Criteria
Skeletal Muscle Conditions
Muscle Relaxants	Generic: carisoprodol carisoprodol and aspirin carisoprodol, aspirin, and codeine chlorzoxazone cyclobenzaprine methocarbamol tizanidine	Amrix Femid Parafon Forte DSC Robaxzin Skelaxin Soma Soma Compound Soma Compound with Codeine Zanaflex	Prior Authorization Criteria
Topical Inflammations
Topical Anti-inflammatory Medications	Some generic preparations available	Elidel Locoid Protopic	Prior Authorization Criteria

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Updated: March 25, 2010