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NC Medicaid Standard Drug Prior Authorization Form

NC Medicaid Direct uses the Prescription Standard Drug Prior Authorization Form for drugs that need prior authorization or a preferred drug list exception. Prescribers meet it when a beneficiary needs a non-preferred drug or one with clinical criteria and no drug-specific form. Prime Therapeutics, the pharmacy benefit administrator, reviews the diagnosis, the non-preferred checklist and the clinical justification across the form's three pages.

Who completes it

The prescriber or their office completes the requester, beneficiary, prescriber, drug, dispensing and diagnosis sections and the clinical justification, and the prescriber signs to attest the information is true and accurate.

Submitting and payment

How to submit it
Fax all three pages with chart notes or lab data to the number printed on the form, or mail them to the Prime Therapeutics prior authorization program; the PBA portal and ePA are other options.

Good to know

  • For a non-preferred drug, check the reason: failure of two preferred drugs (or one if only one exists), allergy or interaction, side effects, contraindication, a unique FDA- or literature-supported indication, or risky switching.
  • Lab results with dates must be provided when they are needed to establish the diagnosis or evaluate the response to therapy.
  • Renewal requests give the date therapy began and the specific dates of therapy so far.
  • Standard plans share the NC Medicaid PDL but run their own PA intake. Antipsychotics have separate A+KIDS and ASAP forms.

Get the official form

Download the current version from the source each time; forms change without notice.

NC Medicaid Prescription Standard Drug Prior Authorization Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does the NC Medicaid standard drug PA form apply to managed care members?

It is the NC Medicaid Direct form administered by Prime Therapeutics. Standard plans use the same NC Medicaid preferred drug list but run their own prior authorization intake, so requests for their members go to the member's plan.

What counts as a reason for a non-preferred drug on the NC form?

The checklist accepts trial and failure of at least two preferred drugs, or one if only one is available; documented allergy or drug interaction; unacceptable side effects; a contraindication or co-morbidity; a unique indication supported by the FDA or peer-reviewed literature; or unacceptable clinical risk from switching.