Colorado Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

A Colorado Medicaid prior authorization form is used for members of the Medicaid program who wish to request a drug that is not on the preferred drug list (PDL). In order for a patient to receive non-preferred medication, the prescribing physician must fill out the prior authorization form, submit it to the Department of Health Care Policy & Financing, and await a reply. The Department will make a decision based on the physician’s medical reasoning and will only approve the medication if they agree with the medical justification. If the request form is denied, the patient has the option of either choosing a drug on the PDL or paying for the prescribed medication out of pocket.

How to Write

Step 1 – At the top of the prior authorization form, enter the request date.

Step 2 – In the “Patient Information” section, enter the patient’s last name, first name, Medicaid ID number, and date of birth.

Step 3 – Under “Prescriber Information”, enter the prescribing physician’s last name, first name, address, phone number, fax number, NPI number, and DEA number.

Step 4 – The “Drug Information” section asks for the name of the drug requested as well as the quantity and frequency of dosing. Next, provide the diagnosis, method of diagnosis, previous medications that did not work for the patient, any allergies the patient has, current medications the patient is using, any relevant lab values, and the date of lab results. Below that is space for the medical justification for prescribing this non-preferred medication. Tick one of the boxes to disclose the location of administration of the medication, should the request be approved.

Step 5 – The prescribing physician must include their signature at the bottom of the page along with the current date.