Illinois Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

An Illinois Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug in the State of Illinois. In your request, you will be asked to provide all information relevant to the patient’s diagnosis and drug trials. You must be able to justify your reason for not prescribing a drug from the Preferred Drug List (PDL). Alternatively, you can call the number provided below and make your request over the phone.

Fax – 1 (217) 524-7264

Phone – 1 (800) 252-8942

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

How to Write

Step 1 – Begin by downloading the PDF version of this form. Then, start filling it out by entering the patient’s full name, date of birth, and HFS Recipient number into the “Patient information” section.

Step 2 – Next, beneath “Prescriber information,” you must enter the full name, phone number, fax number, and NPI number of the prescriber.

Step 3 – If a pharmacy is filling this request, complete the “Pharmacy information” section by providing the pharmacy name, phone number, fax number, and NPI number.

Step 4 – In the “Contact person for this request” field, you must provide the name, phone number, and fax number of the appropriate contact person.

Step 5 – Below the sections listed above, enter the name, strength, quantity, number of refills, NDC number, beginning date of prescription, whether this is a new prescription or a renewal, and the directions for use of the drug in question.

Step 6 – Next, you will need to enter the “Indication, Diagnosis or ICD-9 Code” into the indicated space.

Step 7 – Below that, describe previous drug therapies tried, their reason for failure, and provide any additional reasons for requesting that this particular medication be covered by Medicaid. If you are requesting an override of a specific limitation, check the appropriate box(es) where indicated.

Step 8 – Finally, you must provide your signature and the date in order to complete the form.