Iowa Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – First, download the PDF version of the form and open it with Adobe Acrobat or Microsoft Word.

Step 2 – Fill out the first section of the form by entering the following information:

  • Patient’s Medicaid member ID number, full name, date of birth, and complete address
  • Provider’s NPI number, full name, phone number, complete address, and fax number
  • Pharmacy name, complete address, phone number, NPI number, fax number, and NDC number

Step 3 – Next, you must enter the following information regarding the drug that you are requesting coverage for:

  • Drug name
  • Strength
  • Dosage instructions
  • Quantity
  • Days supply
  • Relevant diagnosis

Step 4 – Below that, you must describe the previous therapy (or therapies) that you have tried and failed in the treatment of this patient’s relevant diagnosis. You must also list any other reasons, lab data, medical conditions, or information that have necessitated this request.

Step 5 – Finally, you must provide your signature and the date.