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Arizona Medicaid Prior (Rx) Authorization Form

An Arizona Medicaid prior authorization form is used by a medical office to request state Medicaid coverage for the prescription of a non-preferred drug. The physician making this request must provide medical justification for not using a preferred drug to treat their patient. This is often due to a patient's allergies to or intolerance of a medication.
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Fax – 1 (877) 422-8130

Phone – 1 (800) 322-8670

Preferred Drug List – List of pre-approved drugs by the State