eForms Logo

California Medicaid Prior (Rx) Authorization Form

A California Medicaid prior authorization form is a request document that must be completed by a physician prescribing a non-preferred drug for a patient using Medi-Cal. If a doctor wishes to prescribe a medication that is not on the state's preferred drug list (PDL), they must justify their diagnosis and treatment using this form.
4.0 Stars | 4 Ratings
Downloads: 210

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