North Dakota Medicaid Prior Authorization Form

Updated January 23, 2022

North Dakota Medicaid prior authorization form allows a medical practitioner to request Medicaid coverage on behalf of a patient for non-preferred drugs in the state of North Dakota. This form issues the specific request and details the prescriber’s justification for making this request. The prescriber should provide any supporting clinical documentation by attaching it to their request form. A PDF version of the North Dakota Medicaid Prior Authorization Form, which can be filled out using either Adobe Acrobat or Microsoft Word, can be downloaded here.

Fax – 1 (701) 328-1544

Preferred Drug List

How to Write

Step 1 – Begin filling out the form by entering the following information into the appropriate fields:

  • Recipient name
  • Recipient date of birth
  • Recipient Medicaid ID number
  • Prescriber name
  • Prescriber NPI
  • Prescriber telephone number and fax number
  • Prescriber complete address

Step 2 – Next, you will need to enter the name of the requested drug, the dosage, and the diagnosis relevant to this request.

Step 3 – You will then need to indicate if the patient had one or more failed treatments using a preferred drug. If this is the case, provide the start date, end date, dosage, and frequency. If the patient had an adverse reaction to a preferred drug, check the appropriate box, and attach the requisite FDA Medwatch Form(s).

Step 4 – In the “Primary Insurance Requires” section, check the indicated box if this a “generic non-preferred product” and supply the name of the “Primary insurance carrier.” You must then check the box that indicates that you have considered the generic/preferred alternatives and that the requested drug is expected to deliver a better result.

Step 5 – If you are making this request from the patient’s pharmacy, enter the pharmacy name, ND Medicaid number, telephone number, fax number, drug name, and NDC# into the indicated fields of the “To Be Continued By Pharmacy” section.

Step 6 – Once completed, print the form.

Step 7 – Provide the prescriber/staff/pharmacy signature and the date.

Step 8 – Fax the form to the appropriate directory.