Pharmacy Prior Authorization Submission Process/Fax Forms

Pharmacy Prior Authorization (PA) requests may be processed by phone, fax, U.S. mail, or electronic submission. Prescribers can find Preferred and Non-Preferred Drug status in each therapeutic category on the Preferred Drug List, and PA Criteria can be found here.

Pharmacy PAs will be processed within 24 hours from when the request is received unless it is necessary for the PA request to be pended to obtain additional information. In that case, the PA may take an additional 24 hours from receipt.

Prior Authorization also includes the A+KIDS program for documenting safety protocols for safe and efficacious prescribing of antipsychotics to NC Medicaid and Health Choice beneficiaries up to and including 17 years of age.

Pharmacy forms may be faxed to 1-833-727-3741; or mailed to PerformRx, 200 Stevens Drive, Philadelphia, PA 19113 c.c. 236

PRIOR AUTHORIZATION FAX FORMS

Antinarcolepsy