Delaware Medicaid Prior (Rx) Authorization Form

Updated December 31, 2021

A Delaware Medicaid prior authorization form is used by healthcare providers wishing to request Medicaid coverage for a patient’s prescription. When making a prior authorization request, the physician must provide supporting documentation and a written justification for requesting coverage of the specific medication in question. Call the number below if you require more information.

DMMA Provider Relations Phone # – 1 (800) 999-3371

Delaware Medical Assistance Portal (DMAP)

DMAP Preferred Drug List – List of pre-approved drugs by the State

How to Write

Step 1 – Begin by entering the full name, date of birth, member ID, allergies (if any), and type of reaction(s) of the patient into the “Member Information” section.

Step 2 – Beneath “Pharmacy Information,” provide the pharmacy name and phone number.

Step 3 – Next, write the name, dosage and frequency, quantity, length of therapy, and the relevant diagnosis of the drug that you are requesting coverage for.

Step 4 – In the “PDL/Formulary Alternatives That Have Been Used By the Patient” section, you are required to list the name, strength, dates tried, and reason for failure of any other drugs that have been used to treat the relevant diagnosis.

Step 5 – Below that, indicate whether the patient is currently or was recently hospitalized, and if applicable enter their date of discharge.

Step 6 – In the field below “Additional Clinical or Supporting Information,” write your justification for requesting coverage for this medication. Include any office notes, lab data, or other supporting medical literature (these can be attached to your submission).

Step 7 – Finally, in the “Prescriber Information” section, enter your full name, your specialty, your NPI number, your office phone number, a contact person, their extension, your office fax number, your written signature, and the date.

Step 8 – Once completed, fax the form to the appropriate directory.