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Arizona Medicaid Prior (Rx) Authorization Form

Arizona Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

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 medical professional making this request will be required to provide medical justification for not using a preferred drug in the treatment of the relevant diagnosis. Usually, this is due to a patient’s allergies/intolerance to a drug, or because preferred drugs have been tried and failed to provide adequate therapy. Prior authorization requests in Arizona are submitted to the Arizona Health Care Cost Containment System (AHCCCS), which is the government branch responsible for handling the state’s Medicaid.

Fax – 1 (877) 422-8130

Phone – 1 (800) 322-8670

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