California Medicaid Prior (Rx) Authorization Form

Updated June 02, 2022

A California Medicaid prior authorization form is a request document that must be completed by a physician prescribing a drug for a patient using Medi-Cal that is not on the state’s Preferred Drug List (PDL). Medi-Cal pharmacy benefits cover most prescription medications but, if a doctor deems it medically necessary to prescribe medication not on the PDL, they must justify their diagnosis in the prior authorization form. The reviewing process could take quite a few days and just because a physician provides solid medical reasoning does not mean the request will be approved. Patients will be informed of their options should the prior authorization request be denied.

Note that the contact information differs depending on the type of California Medicaid prior authorization form request.

  • Self-administered non-specialty medications (US Script)
    • Fax number:1 (866) 399-0929
    • Phone number: 1 (877) 277-0413
  • Self-administered specialty medications (AcariaHealth)
    • Fax number: 1 (855) 217-0926
    • Phone number: 1 (855) 535-1815
  • Physician-administered specialty medications (California Health & Wellness Pharmacy Department)
    • Fax number: 1 (877) 259-6961
    • Phone number: 1 (877) 658-0305

Preferred Drug List

How to Write

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

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

Step 3 – The second section involves insurance information. Enter the primary and secondary insurance name and the patient’s ID numbers.

Step 4 – Under “Prescriber Information”, enter the prescriber’s full name, specialty, address, office contact person, NPI number, phone number, DEA number, fax number, and email address.

Step 5 – Next, you are required to input information concerning the requested medication. Enter the name of the medication and tick the new therapy or renewal box, depending on the type of request. Provide the date the therapy initiated (if renewal) and the duration of therapy. If the patient received the medication under insurance, tick the “paid under insurance” box and provide the name and prior authorization number of the previous request. Tick “other” if it was not paid under insurance and explain the reason.

Step 6 – Provide the dose/strength, frequency, length of therapy/number of refills, and quantity of the drug being requested.

Step 7 – You must also include how the medication will be administered. Tick the box next to the appropriate type of administration. Furthermore, disclose the location of administration by selecting one of the 7 boxes.

Step 8 – At the top of the second page, enter the patient’s name and ID#.

Step 9 – If the patient has been treated for their condition with any other medications, select “YES” and enter the names, dosage, duration, and reason for discontinuation for each medication. Otherwise, select “NO”.

Step 10 – List the diagnoses and provide the appropriate codes.

Step 11 – Section (3) on page two of the request form provides space for you to include medical reasoning and justification for prescribing this drug. You may choose to attach any documents or results that will help support your PA request.

Step 12 – Include your signature and the current date at the bottom of the page.