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NC Medicaid »   Home

Pharmacy Services Clinical Coverage Policies

Clinical Coverage Criteria and Prior Approval request forms
Preferred Drug List (PDL)

Files

9.pdf

9, Outpatient Pharmacy Program

PDF • 892.38 KB - July 08, 2021

9A.pdf

9A, Over-The-Counter Products

PDF • 300.15 KB - January 13, 2020

9B.pdf

9B, Hemophilia Specialty Pharmacy Program

PDF • 308.74 KB - January 13, 2020

9D.pdf

9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17

PDF • 314.6 KB - January 13, 2020

9E.pdf

9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older

PDF • 300.96 KB - January 13, 2020

Aduhelm Injection.pdf

PA Criteria Aduhelm Injection

PDF • 245.69 KB - April 08, 2022

Agents for Duchenne Muscular Dystrophy.pdf

Prior Approval Criteria: Agents for Duchenne Muscular Dystrophy

PDF • 234.72 KB - October 04, 2021

Antifungal-Agents-Vusion.pdf

Prior Approval Criteria: Antifungal-Agents Vusion

PDF • 214.12 KB - May 05, 2021

Antinarcolepsy-Antihyperkinesis-Agents.pdf

Prior Approval Criteria: Antinarcolepsy / Antihyperkinesis Agents

PDF • 290.84 KB - May 06, 2021

Antiparkinsons Agents.pdf

Antiparkinsons Agents

PDF • 250.64 KB - October 04, 2021

Cialis.pdf

Prior Approval Criteria: Cialis

PDF • 186.31 KB - May 05, 2021

Crinone.pdf

Prior Approval Criteria: Crinone

PDF • 188.11 KB - May 06, 2021

Cystic Fibrosis.pdf

Prior Approval Criteria Cystic Fibrosis

PDF • 264.09 KB - February 04, 2022

Emend-Antiemetic-Agents.pdf

Prior Approval Criteria: Emend Antiemetic Agents

PDF • 243.3 KB - May 06, 2021

Emflaza.pdf

Prior Approval Criteria: Emflaza

PDF • 194.89 KB - May 05, 2021

Entresto.pdf

Prior Approval Criteria: Entresto

PDF • 188.82 KB - May 05, 2021

Epidiolex.pdf

PA Criteria Epidiolex

PDF • 263.54 KB - April 08, 2022

Epinephrine-Auto-Injectors.pdf

Prior Approval Criteria: Epinephrine Auto Injectors

PDF • 159.89 KB - May 05, 2021

Evrysedi.pdf

Prior Approval Criteria: Evrysedi

PDF • 242.39 KB - May 06, 2021

Gattex.pdf

Prior Approval Criteria: Gattex

PDF • 230.95 KB - May 06, 2021

Gocovri-Osmolex.pdf

Prior Approval Criteria: Gocovri & Osmolex

PDF • 143.43 KB - May 05, 2021

Growth-Hormone.pdf

Prior Approval Criteria: Growth Hormone

PDF • 289.42 KB - May 06, 2021

Hematinics.pdf

Prior Approval Criteria: Hematinics

PDF • 223.43 KB - May 06, 2021

Hepatitis C.pdf

Prior Approval Criteria Hepatitis C Medications

PDF • 368.81 KB - February 04, 2022

Hetlioz.pdf

Prior Approval Criteria Hetlioz

PDF • 260.76 KB - February 04, 2022

Ivermectin PA Criteria.pdf

Prior Approval Criteria: Ivermectin

PDF • 258 KB - September 22, 2021

Juxtapid.pdf

Prior Approval Criteria: Juxtapid

PDF • 208.27 KB - May 06, 2021

Lupus Medications.pdf

Prior Approval Criteria: Lupus Medications

PDF • 308.52 KB - October 04, 2021

Migraine Therapy.pdf

PA Criteria Migraine Therapy

PDF • 290.02 KB - April 08, 2022

Monoclonal Antibody.pdf

Prior Approval Criteria: Monoclonal Antibodies

PDF • 273.16 KB - October 04, 2021

Movement-Disorders.pdf

Prior Approval Criteria: Movement Disorders

PDF • 234.8 KB - May 06, 2021

Mu-Opioid-Receptor-Antagonists-Relistor.pdf

Prior Approval Criteria: Mu-Opioid Receptor Antagonists

PDF • 168.76 KB - May 06, 2021

Neuromuscular-Blocking Agents.pdf

Prior Approval Criteria: Neuromuscular Blocking

PDF • 323.73 KB - October 04, 2021

Opioid Analgesics.pdf

Prior Approval Criteria Opioid Analgesics

PDF • 305.53 KB - February 04, 2022

Opioid-Dependence-Therapy-Agents.pdf

Prior Approval Criteria: Opioid Dependence Therapy Agents

PDF • 279.06 KB - May 07, 2021

PCSK9.pdf

Prior Approval Criteria PCSK9 Inhibitors

PDF • 309.9 KB - February 04, 2022

Sedative-Hypnotics.pdf

Prior Approval Criteria: Sedative Hypnotics

PDF • 366.19 KB - May 07, 2021

Synagis Criteria.pdf

PDF • 212.1 KB - August 13, 2021

Systemic Immumodulators.pdf

Prior Approval Criteria: Systemic Immunomodulators

PDF • 419.13 KB - October 04, 2021

Continuous Glucose Monitoring System and Related Supplies.pdf

PA Criteria CGM and Related Supplies

PDF • 245.21 KB - April 08, 2022

Topical-Antihistamines.pdf

Prior Approval Criteria: Topical Antihistamines

PDF • 198.99 KB - May 07, 2021

Topical-Anti-Inflammatory-Medications.pdf

Prior Approval Criteria: Topical Anti-Inflammatories

PDF • 179.55 KB - May 07, 2021

Topical-Local-Anesthetics.pdf

Prior Approval Criteria: Topical Local Anesthetics

PDF • 197.9 KB - May 07, 2021

Triptans.pdf

Prior Approval Criteria: Triptans

PDF • 215.7 KB - May 07, 2021

Zolgensma.pdf

Prior Approval Criteria Zolgensma

PDF • 271.72 KB - February 04, 2022

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Division of Health Benefits

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https://medicaid.ncdhhs.gov/pharmacy-services-clinical-coverage-policies