Pharmacy Prior Authorizations
Prior authorization is required for certain drugs prescribed to AmeriHealth Caritas members. Our Pharmacy Services department at AmeriHealth Caritas North Carolina reviews pharmacy prior authorizations to make sure your prescribed medications are safe and appropriate.
Reasons your medication may require preauthorization:
- The medication is not preferred and other alternatives are recommended.
- The dose is outside FDA recommendations.
- The medication is a high risk for abuse or misuse.
- The medication requires additional information.
See Pharmacy Clinical Coverage Policies for more details, including Pharmacy Prior Authorization Criteria.
How to submit a request for pharmacy prior authorizations
- Download and complete the appropriate prior authorization form from the list below.
- Fax your completed Prior Authorization Request Form to 1-877-234-4274 or call 1-866-885-1406, 7 a.m. to 6 p.m., Monday through Saturday.
If you have questions after business hours (Sunday and holidays) call Member Services at 1-855-375-8811 (TTY 1-866-206-6421).
For general pharmacy prior authorization requests (drugs or classes that do not have a form below), complete the Online Pharmacy Prior Authorization Request Form.
Emergency supply
In the event a member needs to begin therapy with a medication before you can obtain prior authorization, pharmacies are authorized to dispense up to a 72-hour emergency supply.
Prior authorization forms
Download and submit the following forms to submit pharmacy prior authorization requests.
- Provigil, Nuvigil, Armodafinil, Modafinil PDF
- Sunosi PDF
- Wakix PDF
- Xyrem PDF
- Xywav PDF
- Epclusa PDF
- Harvoni Tablet/Pellet Pack/Ledipasvir-Sofosbuvir PDF
- Mavyret PDF
- Sofosbuvir-Velpatasvir (generic Epclusa) PDF
- Sovaldi PDF
- Viekira PDF
- Vosevi PDF
- Zepatier PDF
- Adult Onset Still's Disease PDF
- Ankylosing Spondylitis PDF
- Cryopyrin — Associated Periodic Syndromes (CAPS) including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS) PDF
- Crohn's Disease (Adult) PDF
- Crohn's Disease (Pediatric) PDF
- Cytokine Release Syndrome PDF
- Deficiency of Interleukin-1 Receptor Antagonist (DIRA) PDF
- Familial Mediterranean Fever (FMF) PDF
- Giant Cell Arteritis PDF
- Hidradenitis Suppurativa PDF
- Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD) PDF
- Neonatal Onset: Multi-System Inflammatory Disease PDF
- Neuromyelitis Optica Spectrum Disorder (NMOSD) PDF
- Non-Infectious Intermediate Posterior Panuveitis PDF
- Non-Radiographic Axial Spondyloarthritis PDF
- Oral Ulcers Associated with Behcet's Disease PDF
- Plaque Psoriasis (Adult) PDF
- Plaque Psoriasis (Pediatric) PDF
- Polyarticular Juvenile Idiopathic Arthritis (PJIA) PDF
- Psoriatic Arthritis PDF
- Rheumatoid Arthritis PDF
- Systemic Onset Juvenile Idiopathic Arthritis (SJIA) PDF
- Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) PDF
- Ulcerative Colitis (Adult) PDF
- Ulcerative Colitis (Pediatric) PDF
- Dupixent: Asthma PDF
- Dupixent: Atopic Dermatitis PDF
- Dupixent: Nasal Polyps PDF
- Fasenra PDF
- Nucala PDF
- Xolair PDF
- Austedo PDF
- Ingrezza PDF
- Xenazine and Tetrabenazine PDF
- Aduhelm PDF
- A+KIDS (Antipsychotics-Keeping it Documented for Safety) PDF
- ASAP (Atypical Antipsychotics) PDF
- Benlysta PDF
- Cialis PDF
- Continuous Glucose Monitors PDF
- Crinone PDF
- Cystic Fibrosis Medications PDF
- Emend PDF
- Emflaza PDF
- Entresto PDF
- Epidiolex PDF
- Epinephrine Products PDF
- Evrysdi PDF
- Exondys 51 PDF
- Gattex PDF
- Gocorvi and Osmolex ER PDF
- Growth Hormone — Adult 21 Years of Age and Older PDF
- Growth Hormone — Children Less than 21 Years of Age PDF
- Hemantics (Procrit, Epogen, Aranesp, Mircera, Retacrit) PDF
- Hetlioz and Hetlioz LQ PDF
- Inbrija and Ongentys PDF
- Ivermectin PDF
- Juxtapid PDF
- Lupkynis PDF
- Migraine Calcitonin Agents (Non-Acute Treatment) PDF
- Migraine Calcitonin Agents (Acute Treatment) PDF
- Neuromuscular Blocking Agents (Botox, Dysport, Myobloc, Xeomin) PDF
- Non-Covered State Medicaid Plan Service Request Form for Recipients under 21 Years Old PDF
- Opioid Dependence Therapy Agents PDF
- PCSK9 Inhibitors PDF
- Relistor PDF
- Sedative Hypnotics PDF
- Standard Drug Request Form PDF
- Synagis PDF
- Topical Antihistamines PDF
- Topical Anti-Inflammatories PDF
- Topical Local Anesthetics PDF
- Triptans PDF
- Vusion PDF
- Vyondys 53 and Viltepso PDF
- Zolgensma PDF