Georgia Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Georgia Medicaid prior authorization form is used by medical professionals in Georgia to request Medicaid coverage of a non-preferred drug on behalf of a patient. In addition to filling out this form, any supporting medical documentation and notes that help to justify this request must be included. When submitting this form, please consult your directory for the correct fax number to send your request to.

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

How to Write

Step 1 – Download the fillable PDF version of the form and open it using Adobe Acrobat or Microsoft Word.

Step 2 – In the “Provider Information” section, type your full name, specialty, fax number, phone number, and office contact name.

Step 3 – Next, enter the patient’s name, Medicaid ID number, date of birth, and any medication allergies into the indicated fields of the “Member Information” section.

Step 4 – In the “Drug Information” section, you must provide the following information:

  • Drug name and strength
  • Dosage form
  • Dosage Interval
  • Quantity per day
  • Diagnosis relevant to this request
  • Expected length of therapy

Step 5 – In the “Medication History for this Diagnosis” section, you must use the checkboxes to indicate if the patient is currently taking this medication and the duration of this is a request for continuation of a previous approval and if the dosage will be increased or decreased. Next, you must list the name, dates of therapy, and reason for discontinuation of any medications that the patient has been prescribed to treat the relevant diagnosis.

Step 6 – In the blank field below the “Rationale for Request/Pertinent Clinical Information” heading, you will have to describe your justification for making this request.

Step 7 – Type the date into the indicated field at the bottom of the page and print the completed form.

Step 8 – Provide your written signature where indicated, then fax your form and additional documentation to the appropriate directory.