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Connecticut Medicaid Prior (Rx) Authorization Form

Connecticut Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

A Connecticut Medicaid prior authorization form is used by physicians to request permission to prescribe a non-preferred drug to their patient. As the state’s managed care organization, the Community Health Network of Connecticut (CHNCT) states that healthcare providers must prescribe generic drugs from the preferred drug list (PDL) when they are available. If a doctor believes that their patient would benefit from non-generic medication, they must fill out a Connecticut Medicaid prior authorization form and submit it to the Department of Social Services (DSS) for review. In order for this request to be approved, the prescriber must explain their diagnosis and justify their medical reasoning as to why this particular medication would better suit their patient’s condition. If the request is denied, the patient may choose to pay for this medication out of pocket or the physician can prescribe a similar drug from the PDL.

  • Phone number: 8 (866) 409-8386
  • Form can be faxed to: 1 (866) 759-4110 OR 1 (860) 269-2035

Services Prior Authorization

  • Medical services PA form can be faxed to: 1 (855) 817-5696

Preferred Drug List