Medicaid Providers

Medicaid Instructions Guide

North Carolina Medicaid Instructions Guide

• English

Medicaid Provider Profile Sheet

North Carolina Medicaid Provider Profile Sheet

• English

Medicaid Cover Letter

North Carolina Medicaid Cover Letter

• English

Medicaid Ancillary Provider Agreement

North Carolina Medicaid Ancillary Provider Agreement

• English

W-9 Form

W-9 Form

• English

Medication Appeal Request Form

Because WellCare Health Plans denied your request for coverage of (or payment for) a prescription drug, you have the right to an appeal.

• English

• English

Medicaid Drug Coverage Request Form

Please use this form to request coverage of a drug that we would not usually cover or would restrict in some way.

• English

• English

Medicaid Prior Authorization Request

Authorization approves the medical necessity of the requested service only. It does not guarantee payment, nor does it guarantee that the amount billed will be the amount reimbursed.

• English

Value-Added Benefit Referral Form

Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. Notification is required for any date of service change.

• English

Antihistamines

Prior Authorization Form

• English

Beneficiary Psychosocial Readiness

Prior Authorization Form

• English

CAPS FCAS MWS

Prior Authorization Form

• English

Constipation Relistor

Prior Authorization Form

• English

Crinone

Prior Authorization Form

• English

Crohn’s Disease (Pediatric)

Prior Authorization Form

• English

Cystic Fibrosis

Prior Authorization Form

• English

Dupixent for Asthma

Prior Authorization Form

• English

Dupixent for Nasal Polyps

Prior Authorization Form

• English

Emflaza

Prior Authorization Form

• English

Epclusa Initial Form

Prior Authorization Form

• English

Epidiolex

Prior Authorization Form

• English

Familial Mediterranean Fever

Prior Authorization Form

• English

Gattex

Prior Authorization Form

• English

Gocovri and Osmolex

Prior Authorization Form

• English

Growth Hormone (Children Less than 21 Years of Age)

Prior Authorization Form

• English

Harvoni (Continuation)

Prior Authorization Form

• English

Hetlioz

Prior Authorization Form

• English

HIDS MKD

Prior Authorization Form

• English

Immunomodulators: Plaque Psoriasis - Pediatric (Enbrel, Stelara, and Taltz)

Prior Authorization Form

• English

Juvenile Idiopathic Arthritis (Actemra SQ, Enbrel, Humira, and Orencia SQ)

Prior Authorization Form

• English

Lidoderm

Prior Authorization Form

• English

Mavyret (Initial)

Prior Authorization Form

• English

Migraine Calcitonin Agents

Prior Authorization Form

• English

Monoclonal Antibody Therapy (Xolair)

Prior Authorization Form

• English

Neuromyelitis Optica Spectrum Disorder

Prior Authorization Form

• English

Non Radiographic Axial Spondyloarthritis

Prior Authorization Form

• English

NOMID

Prior Authorization Form

• English

Nucala

Prior Authorization Form

• English

Osmolex

Prior Authorization Form

• English

Opioid Dependence Therapy Agents

Prior Authorization Form

• English

PCSK9 Inhibitors

Prior Authorization Form

• English

Plaque Psoriasis (Adult)

Prior Authorization Form

• English

Procrit, Epogen, and Aranesp

Prior Authorization Form

• English

Psoriatic Arthritis

Prior Authorization Form

• English

Sedative Hypnotics

Prior Authorization Form

• English

Sofosbuvir-Velpatasvir (Initial)

Prior Authorization Form

• English

Standard Drug Request

Prior Authorization Form

• English

Sovaldi (Continuation)

Prior Authorization Form

• English

Sunosi

Prior Authorization Form

• English

Topical Aneshetics

Prior Authorization Form

• English

Topical Antifungal Agents (Vusion)

Prior Authorization Form

• English

Treatment for Movement Disorders (Ingrezza)

Prior Authorization Form

• English

Ulcerative Colitis (Adult)

Prior Authorization Form

• English

Viekira (Initial)

Prior Authorization Form

• English

Vosevi Initial Form

Prior Authorization Form

• English

Wakix

Prior Authorization Form

• English

Xolair

Prior Authorization Form

• English

Zepatier (Initial)

Prior Authorization Form

• English