Connecticut Medicaid Prior (Rx) Authorization Form

Updated June 02, 2022

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

How to Write

Step 1 -The first section on the Connecticut Medicaid prior authorization form asks for the prescriber and member’s information. Enter the prescriber’s name, member’s name, prescriber’s NPI, member’s ID, prescriber’s phone number, member’s DOB, prescriber’s fax number, and pharmacy’s fax number.

Step 2 – Also within the first section is space to enter the drug being requested as well as the strength, quantity, and frequency of dosing.

Step 3 – Select the option that pertains to your particular situation and fill in only one of the three sections; (13), (14), or (15).

Step 4 – If the option “Brand Medically Necessary Request” pertains to your particular situation, select one or both of the boxes and explain why the generic product was ineffective when administered to your patient.

Step 5 – If the reason for the request is “Early Refill Request”, tick one of the boxes within section (14); change in directions, lost/stolen/other, or vacation supply. Include the appropriate details.

Step 6 – If the drug you wish to prescribe is not on the PDL, fill in the appropriate information under section (15); “Non-Preferred Drug Request”.

Step 7 – In the “Optimal Dose Request” section, tick the box that pertains to your patient’s situation and include the necessary details.

Step 8 – Include your signature on the line provided and enter the current date.