Missouri Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Missouri Medicaid prior authorization form is used by a prescribing medical provider to request treatment that is not covered by their patient’s state health care plan. Missouri’s Medicaid program is managed by MO HealthNet and it offers 3 plans for members to choose from: Home State Health, MissouriCare, or UnitedHealthCare. Most services, including prescription drugs, are covered by all three services, but not all medications are covered. A committee will then decide whether or not this medication is the most viable and cost-effective option for the patient.

  • Department of Social Services (DSS) MO HealthNet Division phone number: 1 (800) 392-8030
  • Form can be faxed to: 1 (573)636-6470
  • Form can be mailed to:
    ATTN: Drug Prior Authorization
    MO HealthNet Division
    P.O. Box 4900
    Jefferson City, MO
    65102-4900

How to Write

Step 1 – Tick the appropriate box next to either initial or renewal request.

Step 2 – Enter the member’s MO HealthNet number, name, and date of birth.

Step 3 – Provide a diagnosis, the date the diagnosis was established, and information regarding the requested drug.

Step 4 – If the patient is currently taking the drug, select yes and input the date the drug was first used and duration of need.

Step 5 – Enter the current drug regimen along with the schedule of dosage.

Step 6 – Include any medications (as well as the dose, regimen, length of use) that were previously prescribed for the patient’s condition.

Step 7 – Medical reasoning must be given as to why the previous medications administered to the patient did not work.

Step 8 – If this is for reimbursement of a brand name drug, enter when this medication was requested and for how long the patient used it. Include any pertinent details.

Step 9 – Enter the requesting physician/advance practice nurse name and title, phone number, fax number, address, and provider taxonomy code.

Step 10 – The physician’s signature is required, along with the current date and MO HealthNet provider identifier.