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Ohio Medicaid Prior Authorization Form

Ohio Medicaid Prior Authorization Form

Updated July 27, 2023

An Ohio Medicaid prior authorization form is used when Ohio-based medical professionals wish to request Medicaid coverage for a non-preferred drug. A non-preferred drug is a drug that is not included on the State’s Preferred Drug List (PDL). A fillable PDF version of this form is available for download on this webpage. For more information, call the PA Helpdesk at the phone number provided below.

Fax – 1 (800) 396-4111

Phone – 1 (877) 518-1546

Preferred Drug List