Nebraska Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Nebraska Medicaid prior authorization form allows a prescribing physician to request medications that are not covered by a patient’s Medicaid plan. This form is used to request a medication that is otherwise not on the preferred drug list (PDL). The physician must prove, with medical reasoning, that this particular drug is the best option for treating their patient’s condition. The form allows the physician to justify their diagnosis and provide clinical information to support their analysis. The Nebraska Medicaid prior authorization form must be signed by the prescribing physician and submitted to the Department of Health and Human Services for review.

How to Write

Step 1 – Enter the plan/medical group name, phone number, and fax number at the top of the page.

Step 2 – The first section, “Patient Information”, requires that you provide the patient’s full name, phone number, address, date of birth, gender, height, weight, and allergies. If the patient has an authorized representative, enter the representative’s name and phone number.

Step 3 – Under “Insurance Information”, enter the name of the patient’s insurance company and their ID number. Provide a secondary insurance name and ID number if applicable.

Step 4 – In the “Prescriber Information” section, enter the prescribing physician’s full name, specialty, address, office contact person, NPI number, phone number, DEA number, fax number, and email address.

Step 5 – The last section of the first page will require the following information concerning the medication being requested:

  • Enter the medication name and whether this is a new prescription or a renewal
  • If this is a renewal, how was this medication paid for?
  • Provide dosage information, frequency, length of therapy, and the quantity
  • Select the box that applies to the way in which the medication will be administered
  • Select the appropriate location of administration

Step 6 – At the top of page two (2), enter the patient’s name again as well as their ID number.

Step 7 – If the patient has tried other medications to treat their condition, select YES and complete the necessary medical information below. Otherwise, select NO.

Step 8 – Write down the diagnoses and their corresponding ICD codes.

Step 9 – Part (3) of the second page provides space for any relevant clinical information that will support the physician’s request for this particular medication. Provide attachments if necessary and tick the box marked “Attachments”.

Step 10 – Prescriber must sign at the bottom and include today’s date.