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