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New Jersey Medicaid Prior Authorization Form

New Jersey Medicaid Prior Authorization Form

Updated July 27, 2023

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

Email FSS_Standard_Medicare@catalystrx.com

Preferred Drug List