Arizona Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

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

How to Write

Step 1 – Begin by indicating whether you would like this request to be standard or expedited by checking the appropriate box.

Step 2 – Next, you will be required to enter the patient’s complete name, their member ID number, their date of birth, and the date into the indicated fields.

Step 3 – You will then be asked to supply the requesting provider’s full name, NPI number, PCP (if different), an office contact person, their direct phone number, and their fax number.

Step 4 – Complete this section by entering the diagnoses relevant to this prescription (up to three (3) diagnoses). Note that you must attach any relevant clinical documentation to this form when you submit it.

Step 5 – In the final section of the form, you must enter the name, dosage, quantity, number of refills, and instructions for use for the requested drug. Next, enter any allergies that the patient may have, any medications that have tried and failed, or that have been contradicted in the treatment of this diagnosis.

Step 6 – If this is a reauthorization of a current prescription, check the box at the bottom of the form and attach the requisite documentation.

Step 7 – Print the form and fax it to the appropriate directory.