Indiana Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

An Indiana Medicaid prior authorization form is a document used by medical professionals to request Medicaid coverage for a prescription drug not listed on the State’s preferred drug list. This form will provide the insurance company with the patient’s diagnosis, previous medications tried and failed, and any other information which could plead a case for the requested medication. Along with this form, you should submit any medical documentation which supports your justification for making this request.

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

How to Write

Step 1 – Download the PDF version of the prior authorization form and open it with either Adobe Acrobat or Microsoft Word.

Step 2 – Begin filling out your form by providing the following patient information into the “Member Information” section:

  • Patient’s full name
  • Member ID number
  • Gender
  • Date of birth
  • Complete address
  • Primary phone number (and alternate if available)
  • Medication allergies (if applicable)

Step 3 – Next, you will enter the following information into the “Prescriber Information” section:

  • Your full name
  • Your specialty
  • Your NPI or DEA number
  • Your group or hospital
  • Complete address of group or hospital
  • Group or hospital phone number
  • Group or hospital fax number
  • Office contact name

Step 4 – In the “Medication Requested” section, you must provide the drug name, dosage/strength, dosage form, route of administration, quantity per day, directions for use, number of refills, and therapy start date.

Step 5 – Next, in the “Diagnosis” section, enter the relevant diagnosis, ICD9 and description of the diagnosis, and the date of diagnosis.

Step 6 – Beneath “Medication History” you will need to indicate whether this is a new prescription or a renewal and whether this is a request for the strength/dosage to be changed. If the patient has been prescribed other medications as treatment for the relevant diagnosis, supply the drug name, strength, dosage, dates of therapy, and a reason for discontinuation for each applicable drug.

Step 7 – In section “VI” of the form, you must indicate your reason for requesting this coverage and provide your clinical reasons that justify your request.

Step 8 – Type the date beneath the appropriate signature field (either “Dispense as Written” or “Substitution Permitted”) and print the form. Once printed, handwrite your signature in the appropriate field before faxing the form and supporting documents to the proper directory.