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Iowa Medicaid Prior (Rx) Authorization Form

Iowa Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

An Iowa Medicaid prior authorization form is used by a medical office to request Medicaid coverage for non-preferred medications on behalf of patients who are Iowa State Medicaid members. On this webpage, we have provided a downloadable PDF version of this form. You may also use the Provider Portal (link found below) in order to make a prior authorization request online.

Fax – 1 (800) 574-2515

Phone – 1 (877) 776 –1567

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