Medicaid (Rx) Prior Authorization Forms

Updated June 02, 2022

A Medicaid prior authorization forms appeal to the specific State to see if a drug is approved under their coverage. This form is to be completed by the patient’s medical office to see if he or she qualifies under their specific diagnosis and why the drug should be used over another type of medication. Policies may vary between each states’ department of health but the process more or less remains the same. The PDF attached to this page is an example of a typical prescription drug prior authorization request form. Forms should be faxed or mailed to the managed care organization to which the patient belongs.

By State

How to Write

Step 1 – At the top of the page, enter the plan/medical group name, the plan/medical group phone number, and the plan/medical group fax number.

Step 2 – In the “Patient Information” section, enter the patient’s full name, phone number, address, DOB, gender, height, weight, allergies, and authorized representative information (if applicable).

Step 3 – Under “Insurance Information”, provide the names and numbers of the patient’s primary and secondary insurance.

Step 4 – The third section demands the physician’s name, specialty, address, contact person, NPI number, phone number, DEA number, fax number, and email address.

Step 5 – In the “Medication” section, provide the necessary information concerning the prescription drug being requested. Include the name, dose, frequency, length of therapy, quantity, administration, and administration location.

Step 6 – At the top of page two (2), enter the patient’s name and ID number.

Step 7 – Section (1) of page two should be filled in if the patient has tried other medication for their condition. List the names of these medications, duration of therapy, and the response to this drug.

Step 8 – Section (2) of page two is where the physician will list the diagnoses with the associated ICD codes.

Step 9 – Under “Required Clinical Information”, provide any lab results, comments, or additional information that will support the medical reasoning for prescribing this medication.

Step 10 – Prescriber must sign the bottom and include the current date.