New Hampshire Medicaid Prior Authorization Form

Updated January 23, 2022

New Hampshire Medicaid prior authorization form allows a New Hampshire-based medical professional to request Medicaid coverage for a non-preferred drug. Using this form and any supporting medical documentation that you can supply, you will need to provide your clinical justification for not prescribing a drug on the Preferred Drug List (PDL). Once you have completed filling out your form, fax it along with any other attachments to the fax number provided below.

Fax – 1 (888) 603-7696

Phone – 1 (866) 675-7755

Preferred Drug List – Drugs considered preferable by the State

How to Write

Step 1 – Download the fillable PDF form and open it using Adobe Acrobat or Microsoft Word.

Step 2 – Enter the date at the top of the page.

Step 3 – Next, enter the patient’s name, Medicaid number, date of birth, and gender into the indicated fields of “Section I.”

Step 4 – In “Section II,” you will need to provide the relevant medical diagnosis, drug name, strength, dosing directions, and length of therapy.

Step 5 – In “Section III,” you will need to use the checkboxes and blank fields to indicate the circumstances that have necessitated this request. First indicate if the patient had an allergic and/or drug-to-drug interaction, and describe their reaction. If any of the following situations apply to the situation, tick the appropriate checkboxes and fill their related fields:

  • Previous episode of an unacceptable side effect or therapeutic failure
  • Clinical/unique patient contraindication
  • Age-specific indications
  • Unique clinical indication supported by FDA approval/peer-reviewed literature
  • Unacceptable clinical risk associated with therapeutic change

Step 6 – Next, provide your name, NPI number, phone number, and fax number into the indicated fields of “Section IV.”

Step 7 – Enter the date in the bottom right-hand corner and print the form. Add your handwritten signature where indicated and fax your form to the appropriate directory.