Medicaid Cover Letter

North Carolina Medicaid Cover Letter

• English

Medicaid Participating Provider Agreement

North Carolina Medicaid Participating Provider Agreement

• English

W-9 Form

W-9 Form

• English

Medicaid Instructions Guide

North Carolina Medicaid Instructions Guide

• English

Medicaid Ancillary Profile Sheet

North Carolina Medicaid Ancillary Profile Sheet

• 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

YMCA Provider Referral Replacement Form

YMCA Provider Referral Replacement Form

• 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

Ankylosing Spondylitis (Enbrel, Humira, Simponi, and Cimzia)

Prior Authorization Form

• English

Botox, Dysport, Myobloc, and Xeomin

Prior Authorization Form

• English

Crinone 8% Gel

Prior Authorization Form

• English

Cryopyrin-Associated Periodic Syndromes (Kineret)

Prior Authorization Form

• English

Dupixent for Atopic Dermatitis

Prior Authorization Form

• English

Emflaza

Prior Authorization Form

• English

Exondys 51

Prior Authorization Form

• English

Growth Hormone (Adult 21 Years of Age and Older)

Prior Authorization Form

• English

Hidradenitis Suppurativa (Humira)

Prior Authorization Form

• English

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

Prior Authorization Form

• English

Lidoderm

Prior Authorization Form

• English

Mavyret (Continuation)

Prior Authorization Form

• English

Monoclonal Antibody Therapy (Nucala)

Prior Authorization Form

• English

Neonatal Onset Multi-System Inflammatory Disease (Kineret)

Prior Authorization Form

• English

Non-Steroidal Anti-inflammatory Drugs including Cox-2 Inhibitors

Prior Authorization Form

• English

Opioid Analgesic (Short-Acting)

Prior Authorization Form

• English

Plaque Psoriasis (Enbrel, Humira, and Stelara)

Prior Authorization Form

• English

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

Prior Authorization Form

• English

Provigil and Nuvigil

Prior Authorization Form

• English

Psoriatic Arthritis (Otezla)

Prior Authorization Form

• English

Sedative Hypnotics

Prior Authorization Form

• English

Symdeko

Prior Authorization Form

• English

Treatment for Movement Disorders (Ingrezza)

Prior Authorization Form

• English

Ulcerative Colitis (Humira and Simponi)

Prior Authorization Form

• English

Vusion

Prior Authorization Form

• English