Idaho Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

An Idaho Medicaid prior authorization form is used by an Idaho-based physician who wishes to request Medicaid coverage for a non-preferred drug prescription. Within this form, you will be required to provide your patient’s medical history in relation to the relevant diagnosis, as well as a clinical justification for this request. Once complete, this form must be faxed to the appropriate Medicaid directory. For more information, call the Idaho Medicaid Pharmacy Call Center number which is provided below.

Phone – 1 (866) 827-9967

How to Write

Step 1 – First download the fillable PDF version of the prior authorization form and open it using either Adobe Acrobat or Microsoft Word.

Step 2 – Once the file is opened, enter your full name, specialty, fax number, phone number, and office contact name into the “Provider Information” section.

Step 3 – Next, enter the patient’s name, ID number, date of birth, and medication allergies (if applicable) into the “Member Information” section.

Step 4 – In the “Drug Information” section, enter the name, strength, dosage form, dosage interval, quantity per day, relevant diagnosis, and the expected length of therapy for the drug prescription for which you are requesting coverage.

Step 5 – Beneath “Medication History for this Diagnosis,” you must indicate whether this is a new prescription or a renewal/request for continuation. If the patient is already on this prescription, you will need to enter the length of time that they have been taking it. Next, indicate whether there is a change in the dosage.

Step 6 – If this is a new request or if there is a change in the dosage, in item “D” you will need to supply the name, dates of therapy, and the reason for discontinuation of previous drug trials made to treat the relevant diagnosis.

Step 7 – In the “Rationale for Request” field, you must provide your clinical justification for this particular request.

Step 8 – Type the date in the indicated field at the bottom of the page and print the completed form. Once the form is printed, sign your handwritten signature in the “Provider Signature” field. The form is now ready to be faxed to the appropriate directory.