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North Carolina Prior Authorization Requirements

Medicare TraditionalMedicaid FFSMedicaid MCOPart DMedicare AdvantageDual-EligibleCommercial (employer / fully-insured)Commercial — Marketplace QHP

PA required

59%

1,090 verified rules

Verified Jun 8, 2026

Service category PA

All programs combined
Durable Medical Equipment
5/6Conditional
Specialty Drugs
5/6Conditional
Mental Health — Inpatient
4/6Conditional
Inpatient Hospital
4/6Conditional
Home Health
4/6Conditional
Skilled Nursing Facility
4/6Conditional
Outpatient Surgery
4/6Conditional
Ambulance Transport
3/6Conditional
Physical Therapy
3/6Conditional
Substance Use Treatment
3/6Conditional
Diagnostic Imaging
3/6Conditional
Speech Therapy
3/6Conditional
Occupational Therapy
3/6Conditional
advanced_imaging
3/6Conditional
Laboratory
0/6No PA

Drug class PA

Part D federal protections flagged
Oral Oncology
15/17Conditional
ADHD Stimulants
15/17Conditional
hereditary_angioedema
12/12Full PA
growth_hormone
12/12Full PA
pulmonary_arterial_hypertension
12/12Full PA
hepatitis_c_daa
11/11Full PA
tnf_inhibitors
11/11Full PA
il_inhibitors_biologics
11/11Full PA
migraine_cgrp
11/11Full PA
ms_disease_modifying
11/11Full PA
asthma_copd_biologics
11/11Full PA
testosterone_androgens
10/11Conditional
antifungals_systemic
10/11Conditional
anticonvulsants
10/12Conditional
glp1_agonists
10/10Full PA
atypical_antipsychotics
10/11Conditional
jak_inhibitors
10/10Full PA
inhaled_respiratory
9/12Conditional
opioid_analgesics
9/11Conditional
other_antidepressants
9/11Conditional
pcsk9_inhibitors
9/10Conditional
antiplatelets
8/12Conditional
Immunosuppressants
7/9Conditional
Rare Disease / Orphan
6/7Conditional
skeletal_muscle_relaxants
6/11Conditional
ppi_acid_reducers
6/11Conditional
opioid_use_disorder
6/12Conditional
oral_retinoids
6/10Conditional
anxiolytics_benzodiazepines
6/11Conditional
nsaids
6/10Conditional
Controlled — Schedule III–V
5/6Conditional
Biosimilars
5/6Conditional
Diabetes — Insulin
5/6Conditional
Specialty Non-Biologic
5/6Conditional
Antipsychotics
5/7Conditional
Brand (No Generic)
5/6Conditional
Brand (Generic Available)
5/6Conditional
Controlled — Schedule II
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Hepatitis C
5/6Conditional
wakefulness_agents
5/5Full PA
other_antidiabetics
5/11Conditional
sedative_hypnotics
5/11Conditional
Specialty Biologics
5/6Conditional
hemophilia_factors
5/5Full PA
Antidepressants
4/6Conditional
dermatology_biologics
4/4Full PA
overactive_bladder
4/11Conditional
enzyme_replacement
4/4Full PA
insulins
4/11Conditional
antihistamines
4/10Conditional
vmat2_inhibitors
4/4Full PA
statins
4/11Conditional
HIV Antiretrovirals
3/17Conditional
arbs
3/11Conditional
dpp4_inhibitors
3/10Conditional
bisphosphonates
3/12Conditional
weight_loss_agents
3/4Conditional
triptans
3/12Conditional
ssri_antidepressants
3/10Conditional
anticoagulants_doac
3/11Conditional
oxybate_salts
3/3Full PA
cystic_fibrosis_modulators
3/3Full PA
dalfampridine
3/3Full PA
immunoglobulins
3/3Full PA
GLP-1 (Weight Loss)
2/6Conditional
als_agents
2/2Full PA
topical_steroids
2/5Conditional
calcium_channel_blockers
2/11Conditional
ophthalmic_anti_inflammatory
2/2Full PA
ace_inhibitors
2/11Conditional
sglt2_inhibitors
2/9Conditional
leukotriene_modifiers
2/11Conditional
infertility_agents
2/2Full PA
hematopoietic_growth_factors
2/2Full PA
erectile_dysfunction
2/2Full PA
oncology_supportive
2/2Full PA
glp1_diabetes
1/1Full PA
alzheimers_agents
1/3Conditional
selective_constipation_agents
1/1Full PA
opioid_antagonists
1/1Full PA
electrolyte_depleters_kidney
1/1Full PA
topical_antifungals
1/1Full PA
neuropathic_pain
1/1Full PA
antianginal_anti_ischemic
1/1Full PA
benign_prostatic_hyperplasia
1/2Conditional
topical_antiparasitics
1/1Full PA
disposable_insulin_delivery_devices
1/1Full PA
antibiotics_penicillins_cephalosporins
1/1Full PA
beta_blockers
1/11Conditional
tobacco_cessation
1/1Full PA
diabetic_supplies
1/2Conditional
antibiotics_macrolides
1/1Full PA
bile_acid_sequestrants
1/1Full PA
colony_stimulating_factors
1/1Full PA
rosacea_agents
1/1Full PA
antibiotics_quinolones
1/1Full PA
cardiovascular_other
1/1Full PA
hematopoietic_agents
1/1Full PA
antibiotics_tetracyclines
1/1Full PA
amylin_analogs
1/1Full PA
thrombopoiesis_stimulating_agents
1/1Full PA
topical_miscellaneous
1/1Full PA
coronary_vasodilators
1/1Full PA
ophthalmic_allergic_conjunctivitis
1/1Full PA
antivirals_general
1/1Full PA
ophthalmic_antibiotics
1/1Full PA
hepatitis_b_antivirals
1/2Conditional
direct_renin_inhibitor
1/1Full PA
atopic_dermatitis_biologics
1/1Full PA
herpes_antivirals
1/1Full PA
niacin_derivatives
1/1Full PA
cannabinoid_antiemetics
1/3Conditional
epinephrine_self_administered
1/1Full PA
influenza_antivirals
1/1Full PA
nitrate_combination
1/1Full PA
bile_acid_salts
1/1Full PA
otic_agents
1/5Conditional
estrogen_agents
1/1Full PA
inhaled_antibiotics
1/1Full PA
h_pylori_combinations
1/1Full PA
glucocorticoid_steroids_oral
1/1Full PA
injectable_antipsychotics
1/1Full PA
acne_agents
1/1Full PA
anti_parkinson_rls
1/1Full PA
ulcerative_colitis
1/1Full PA
topical_antibiotics
1/1Full PA
antiarrhythmics
1/3Conditional
topical_antivirals
1/1Full PA
diabetic_cgm_supplies
1/1Full PA
glaucoma_agents
1/1Full PA
oral_antipsoriatics
1/1Full PA
sympatholytics
1/1Full PA
h2_receptor_antagonists
1/2Conditional
intranasal_rhinitis_agents
1/1Full PA
triglyceride_lowering_agents
1/1Full PA
pancreatic_enzymes
1/1Full PA
progestins_cachexia
1/1Full PA
antivirals_other
1/2Conditional
ssri_snri_other_antidepressants
1/1Full PA
antiparasitics
1/1Full PA
cns_miscellaneous
1/1Full PA
sexual_dysfunction_agents
1/1Full PA
antibacterials_systemic
1/1Full PA
electrolytes_vitamins
1/1Full PA
respiratory_allergy_cough_cold
1/1Full PA
gi_bowel_motility
1/1Full PA
ophthalmic_anti_inflammatory_anti_infective
1/1Full PA
thyroid_agents
1/3Conditional
sleep_and_wakefulness_agents
1/1Full PA
ophthalmic_dry_eye_misc
1/1Full PA
immunological_immunomodulators
1/1Full PA
roflumilast
1/3Conditional
pulmonary_fibrosis
1/1Full PA
metabolic_bone_other
1/1Full PA
osteoporosis_anabolics
1/1Full PA
miscellaneous_specialty
1/1Full PA
cough_cold
1/1Full PA
gi_other
1/1Full PA
estrogens_hrt
1/1Full PA
cannabidiol
1/2Conditional
gnrh_oncology_hormonal
1/1Full PA
other_lipid_agents
1/1Full PA
ophthalmic_agents
1/1Full PA
antibiotics_general
1/1Full PA
il1_other_immunomodulators
1/1Full PA
transplant_immunosuppressants
1/1Full PA
other_cardiovascular
1/1Full PA
parkinsons_agents
1/1Full PA
diuretics
1/3Conditional
continuous_glucose_monitors
1/1Full PA
allergen_immunotherapy
1/1Full PA
endometriosis_agents
1/1Full PA
acromegaly_agents
1/1Full PA
multiple_sclerosis_agents
1/1Full PA
central_precocious_puberty
1/1Full PA
urea_cycle_disorder
1/1Full PA
myasthenia_gravis_agents
1/1Full PA
vasopressins
1/1Full PA
antilipemics_acl_inhibitors
1/1Full PA
bleeding_disorders_agents
1/1Full PA
paroxysmal_nocturnal_hemoglobinuria
1/1Full PA
pulmonary_fibrosis_agents
1/1Full PA
growth_improvement_agents
1/1Full PA
sickle_cell_disease
1/1Full PA
ophthalmic_anti_vegf
1/2Conditional
movement_disorders
1/1Full PA
carnitine_deficiency_agents
1/1Full PA
immunologic_misc
1/1Full PA
narcolepsy_cataplexy_agents
1/1Full PA
cortisol_synthesis_inhibitors
1/1Full PA
fertility_regulators
1/1Full PA
botulinum_toxins
1/1Full PA
hereditary_tyrosinemia
1/1Full PA
platelet_disorders
1/1Full PA
autoimmune_physician_administered
1/1Full PA
dermatology_antipsoriatics
1/1Full PA
oncology_hormonal
1/2Conditional
immunomodulators
1/1Full PA
calcium_regulators_misc
1/1Full PA
alpha1_antitrypsin_deficiency
1/1Full PA
viscosupplements
1/1Full PA
chelating_agents
1/1Full PA
uterine_fibroids
1/1Full PA
calcium_receptor_agonists
1/1Full PA
polyneuropathy_agents
1/1Full PA
dermatology_topical_other
1/1Full PA
calcimimetics
1/1Full PA
hepatitis_b_agents
1/1Full PA
pde4_inhibitors_inflammatory
1/1Full PA
immunosuppressants_misc
1/1Full PA
neuro_psych_misc
1/1Full PA
cough_cold_allergy
1/1Full PA
antibiotics_misc
1/1Full PA
antiparkinson_agents
1/1Full PA
metabolic_disorder_agents
1/1Full PA
il_inhibitors_ibd
1/1Full PA
hematopoietic_esa
1/1Full PA
ovulation_stimulants
1/1Full PA
Opioid Treatment (MOUD)
0/6No PA
Compounded Medications
0/6No PA
antimyasthenic_agents
0/1No PA
antimycobacterials_tb
0/1No PA
antidementia_alzheimers
0/1No PA
dental_oral_agents
0/1No PA
antigout_agents
0/1No PA
bipolar_agents_lithium
0/1No PA
bph_agents
0/2No PA
inflammatory_bowel_disease
0/2No PA
oral_corticosteroids
0/1No PA
vaccines
0/2No PA
ophthalmic_glaucoma
0/2No PA
anaphylaxis_epinephrine
0/1No PA
snri_antidepressants
0/2No PA
contraceptives
0/3No PA
dental_products
0/1No PA
feminine_products
0/1No PA
smoking_cessation
0/1No PA
nutritional_dietary
0/1No PA
vitamins
0/2No PA
antimalarials
0/2No PA
antilipemics_bile_acid_resins
0/1No PA
postherpetic_neuralgia
0/1No PA
antidiarrheals
0/1No PA
ophthalmic_antiglaucoma_beta_blockers
0/1No PA
mast_cell_stabilizers
0/1No PA
antivirals_systemic
0/1No PA
glucose_elevating_agents
0/1No PA
ophthalmic_anti_infectives
0/1No PA
salicylates
0/1No PA
genitourinary_misc
0/1No PA
electrolytes
0/1No PA
dermatology_misc
0/1No PA
anthelmintics
0/2No PA
alpha_blockers
0/1No PA
vaginal_anti_infectives
0/2No PA
prenatal_vitamins
0/1No PA
cold_cough
0/1No PA
dermatology_scabicides_pediculicides
0/1No PA
antidementia_agents
0/1No PA
gi_anticholinergics
0/1No PA
ophthalmic_antiallergics
0/1No PA
mouth_throat_dental_agents
0/1No PA
antitubercular_agents
0/1No PA
antilipemics_fibrates
0/1No PA
smoking_deterrents
0/1No PA
glucocorticoids
0/1No PA
gi_antispasmodics
0/1No PA
ophthalmic_anti_infective_anti_inflammatory
0/1No PA
cephalosporins
0/1No PA
antilipemics_misc
0/1No PA
ophthalmic_anti_inflammatories
0/1No PA
xanthines
0/1No PA
fluoroquinolones
0/1No PA
fibromyalgia_agents
0/1No PA
allergenic_extracts
0/1No PA
dermatology_actinic_keratosis
0/1No PA
anti_infectives_misc
0/1No PA
digitalis_glycosides
0/1No PA
endocrine_metabolic_misc
0/1No PA
dmards
0/1No PA
dermatology_antipruritic
0/1No PA
nitrates
0/1No PA
anaphylaxis_treatment_agents
0/1No PA
dermatology_local_anesthetics
0/1No PA
antibacterials_misc
0/1No PA
vitamin_d_analogs
0/1No PA
dermatology_wound_care
0/1No PA
antilipemics_cholesterol_absorption
0/1No PA
antiparkinsonian_agents
0/1No PA
psychotherapeutic_misc
0/1No PA
ophthalmic_antiglaucoma_combinations
0/1No PA
respiratory_misc
0/1No PA
macrolides
0/1No PA
ophthalmic_carbonic_anhydrase_inhibitors
0/1No PA
dermatology_acne
0/1No PA
laxatives
0/2No PA
ophthalmic_misc
0/1No PA
dermatology_antibiotics
0/1No PA
migraine_ergotamines
0/1No PA
menopausal_symptom_agents
0/1No PA
gastrointestinal_misc
0/1No PA
ophthalmic_prostaglandins
0/1No PA
dermatology_antifungals
0/1No PA
tetracyclines
0/1No PA
direct_renin_inhibitors
0/1No PA
phosphate_binders
0/1No PA
ophthalmic_rho_kinase_inhibitors
0/1No PA
cns_misc
0/1No PA
ulcer_therapy_combinations
0/1No PA
ophthalmic_other
0/1No PA
non_opioid_analgesics
0/2No PA
cardiovascular_misc
0/1No PA
mood_stabilizers
0/1No PA
progestins
0/1No PA
aldosterone_antagonists
0/1No PA
alcohol_deterrents
0/1No PA
musculoskeletal_therapy_agents
0/1No PA
nutritional_misc
0/1No PA
dermatology_rosacea
0/1No PA
gout_agents
0/1No PA
rectal_corticosteroids
0/1No PA
ophthalmic_sympathomimetics
0/1No PA
dermatology_antiseborrheics
0/1No PA
other_antihypertensives
0/1No PA
antimyasthenic_cholinergic
0/1No PA
arni_sacubitril
0/1No PA
anticoagulants_warfarin
0/1No PA
opioid_reversal_antidotes
0/1No PA
other_antihyperlipidemics
0/1No PA
corticosteroids_systemic
0/1No PA
digestive_enzymes
0/1No PA
serms
0/1No PA
interstitial_cystitis
0/1No PA
antianginal_nitrates
0/1No PA
antidiarrheal_probiotic
0/1No PA
antimycobacterial
0/1No PA
antipsoriatics_topical
0/1No PA
estrogens_progestins
0/1No PA
hemostatics
0/1No PA
anticoagulants_heparins
0/1No PA
antiemetics
0/1No PA
vasopressin_desmopressin
0/1No PA
cardiotonics
0/1No PA
vasopressors_anaphylaxis
0/1No PA
anorectal_rectal
0/1No PA
smoking_alcohol_deterrents
0/1No PA
vitamins_minerals
0/1No PA
hematinics_other
0/1No PA
fibromyalgia_snri
0/1No PA
nutritional_metabolic
0/1No PA
mouth_throat_dental
0/1No PA
medical_supplies_devices
0/1No PA
topical_anti_infectives
0/1No PA
vaccines_toxoids
0/1No PA
pharmaceutical_adjuvants
0/1No PA
methadone
0/1No PA
esketamine
0/1No PA

PA type breakdown

clinical_criteria
516
Conditional
81
Full PA
48

Federal protected classes requiring PA

AntipsychoticsPA required
AntidepressantsPA required
AntipsychoticsPA required
Oral OncologyPA required
ImmunosuppressantsPA required
AntidepressantsPA required
ImmunosuppressantsPA required
Oral OncologyPA required

State flags

Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)

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North Carolina Prior Authorization Requirements | Auth57 Labs