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Washington D.C. Medicaid Prior Authorization Form

Updated January 23, 2022

A Washington DC Medicaid Prior Authorization Form can be used when a medical practitioner needs to request Medicaid coverage for a drug that is not on the state-approved Preferred Drug List (PDL). In order for the request to be valid, the prescriber will need to present their medical justification(s) for not prescribing a preferred drug and attach any supporting documents. Once completed, this form must be submitted via fax to the number provided below.

Fax: (866) 535-7622

Help Desk: (800) 273-4962

Preferred Drug List – list of pre-approved drugs in the District of Columbia