Minnesota Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

A Minnesota Medicaid prior authorization form is used when a medical professional wants to request Medicaid coverage in the State of Minnesota for a prescription that is otherwise ineligible for coverage. When submitting this form, the prescriber must include any supporting medical documentation which helps justify their request. For more information, call the phone number provided below.

Fax – 1 (866) 889-6512

Phone – 1 (866) 433-3658

Preferred Drug List – Search for pre-approved drugs online

How to Write

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

Step 2 – Begin by entering your full name, specialty, fax number, phone number, and office contact name into the “Provider Information” section.

Step 3 – In the “Member Information” section, supply the patient’s name, ID number, date of birth, and any medication allergies that they may have.

Step 4 – Beneath the “Drug Information” heading, you must enter the drug’s name, strength, dosage form, dosage interval, quantity per day, relevant diagnosis, and the expected length of therapy.

Step 5 – In the “Medication History for this Diagnosis” section, you will need to indicate whether this is a new prescription or a renewal. If it is a renewal, enter the length of treatment, if this is a request for continuation, and if the dosage will be changed.

Step 6 – If the patient has been prescribed other drugs in treatment for this diagnosis, provide the name, dates of therapy, and reason for discontinuation of each drug.

Step 7 – Beneath “Rationale for Request,” describe your clinical reasons for choosing this prescription and making this request for Medicaid coverage.

Step 8 – Enter the date at the bottom-right corner of the page and print the form. Once the form has been printed, add your handwritten signature in the “Provider Signature” field and send your form with attached documents by fax to the appropriate office.