New Mexico Medicaid Prior Authorization Form

Updated January 23, 2022

A New Mexico Medicaid prior authorization form is a document used by medical professionals to request Medicaid coverage for a non-preferred drug. It’s necessary to provide medical justification for not using a drug from the State-approved Preferred Drug List. Once the form is complete, it needs to be faxed to the correct directory. A downloadable PDF version of the New Mexico Medicaid Prior Authorization Form is available here.

Preferred Drug List

How to Write

When filling out this form, all fields marked with an asterisk are required information.

Step 1 – First use the checkboxes to select if your patient’s primary medical insurance provider is “BCBS,” “Molina,” “Presbyterian,” or “United Healthcare.”

Step 2 – Provide the name of the insurer and the day’s date.

Step 3 – In the “Member Information” section, you will need to provide the patient’s group number, member number, and the name of the insured party. Next, enter the patient’s name, their date of birth, their complete address, and their email address. Then input their primary, mobile, and work phone numbers, their height, weight, and gender, their BIN number, their PCN number, their issuer number, and their employer’s name.

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

  • NPI number
  • DEA/XM number
  • Specialty
  • Group practice or organization name
  • Prescriber’s full name
  • Prescriber’s e-mail address
  • Prescriber’s office contact name
  • Prescriber’s complete office address
  • Prescriber’s phone number and fax number

To provide the prescriber’s signature, either use the Adobe E-Sign function or print the document once it’s completed and provide a handwritten signature.

Step 5 – In the “Requested Medication” section, you will need to enter the relevant diagnoses and indicate whether the patient is pending discharge from a medical facility. You will then need to provide the drug name, J-Code, dosage, frequency, quantity, day’s supply, and number of refills. Beneath “Reason for request/Justifications,” you must provide your clinical reasons and include any available lab details that support your reasons for making this request. To complete this section, you are asked to enter the anticipated start and end dates of therapy.

Step 6  – Finally, in the “Pharmacy/Facility Information” section, you will need to provide the pharmacy NPI number, pharmacy address, pharmacy name, pharmacy fax number, and pharmacy phone number.