Pharmacy Criteria Updates for Systemic Immunomodulators
Effective June 28, 2020, the prior approval (PA) criteria and/or forms for Topical Systemic Immunomodulators will be updated.
At the request of NC Medicaid, these changes will be implemented via system updates in the secure portal, as well as in existing paper drug forms and criteria on the public portal. Please see the summary of changes in the lists below.
Criteria Updates:
- Stelara Infusion
- Skyrizi
- Stelara
- Otezla
- Taltz
Pharmacy PA criteria can be found at:
https://www.nctracks.nc.gov/content/public/providers/pharmacy/pa-drugs-criteria-new-format.html
Form Updates:
- Ankylosing Spondylitis
- Oral Ulcers Associated with Behcet’s Disease
- Non-Radiographic Axial Spondyloarthritis
- Plaque Psoriasis (Adult)
- Psoriatic Arthritis
- Systemic Onset Juvenile Idiopathic Arthritis
- Ulcerative Colitis
- Plaque Psoriasis
Pharmacy PA request forms can be found at: https://www.nctracks.nc.gov/content/public/providers/pharmacy/forms.html
M20149-1-R-2329