Nevada Medicaid Prior Authorization Form

Updated January 23, 2022

Nevada Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug prescription in the state of Nevada on behalf of a certified medical practitioner. You can download a fillable PDF version of this form here. In order for your request to be eligible, you must provide a clinical justification for why you are not opting to prescribe a drug from the PDL (Preferred Drug List). Once completed, fax the prior authorization form to the fax number provided below.

Fax – 1 (855) 455-3303

Phone – 1 (855) 455-3311

Preferred Drug List – Acceptable drugs by the State

How to Write

Step 1 – Begin filling out the form by entering the “Date of Request” and providing the following “Recipient Information” into the appropriate fields:

  • Full name
  • Date of birth
  • Recipient ID
  • Gender
  • Phone number

Step 2 – In the “Prescribing Provider Information” section, you will need to provide your name, NPI number, phone number, fax number, and a contact name.

Step 3 – Next, in the “Diagnosis and Requested Drug” section, enter the ICD-10 code, diagnosis, or symptom into the indicated space. Then, enter the name, strength, dosage, and duration of the drug prescription that you are requesting coverage for. Tick the “Generic substitution not permitted” box if this statement applies to your request.

Step 4 – Beneath “Clinical Information,” you will need to write an explanation of why preferred medications have or will not work in treating your patient, and provide the name, reason for failure, and dates of treatment for each PDL medication that the patient has been unsuccessfully prescribed. Next, if applicable, list any contraindications or drug to drug interactions for the patient, and any additional clinical information.

Step 5 – Next, use the checkboxes to indicate whether the non-preferred drug is being requested for a unique indication, and/or if the member was discharged from a mental health facility on the requested medication (and provide the date of discharge).

Step 6 – Enter the date in the bottom right-hand corner.

Step 7 – Print the form and sign it where indicated.

Step 8 – Fax the form to the appropriate directory.