New Jersey Medicaid Prior Authorization Form

Updated January 23, 2022

New Jersey Medicaid prior authorization form is to be used by a New Jersey-based medical practitioner who needs to request Medicaid coverage for a non-preferred prescription. You can download a fillable PDF version of this form here (compatible with Adobe Acrobat and Microsoft Word). In order for your request to be accepted, you will need to provide clinical justification for not using a preferred drug. A link to the New Jersey Medicaid Preferred Drug List can be found below.

Fax – 1 (888) 671-5285


Preferred Drug List

How to Write

Step 1 – Begin by selecting either “Gender Edit,” “Quantity Edit,” “Age Edit,” or “Prior Authorization” using the provided checkboxes.

Step 2 – Enter the name and quantity for the requested drug into the indicated fields, and indicate whether or not a generic submission would also be acceptable.

Step 3 – Beneath the “Patient Information” heading, you will need to provide the following information:

  • Patient’s name
  • Date of birth
  • Patient’s complete address
  • Patient’s ID number
  • Patient’s office and telephone numbers

Step 4 – Next, in the “Prescriber Information” section, supply all of the information listed below.

  • Prescribing physician’s name
  • Physician’s specialty
  • Provider NPI number
  • Provider’s complete office address
  • Provider’s office contact name
  • Provider’s office fax number

Step 5 – You will then be asked to list all of the provider’s specialties and name the patient’s diagnosis (or diagnoses). Below that, you must list the name and duration of therapy for any current or past drugs the patient has taken in treatment of their current diagnoses. Next to each item, use the checkboxes to indicate whether that drug is currently being prescribed and whether there was a related complaint.

Step 6 – Next, type in any additional clinical information which supports the necessity of your making this request.

Step 7 – Once your form has been completed, either fax a printed version of the form or send it by email to the correct directory (the appropriate fax number and email address to send this form to can be found above).