Ohio Medicaid Prior Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Download and open the PDF version of the Ohio Medicaid Prior Authorization Form.

Step 2 – Enter the date in the “Request Date” field.

Step 3 – Provide the patient’s Medicaid ID number, date of birth, full name, age, height, weight, and sex into the indicated fields.

Step 4 – Next, provide your full name, NPI number, address, phone number, and fax number.

Step 5 – If known, enter the relevant pharmacy’s name and phone number.

Step 6 – Below that, enter the name, strength, route of administration, frequency, duration of therapy, and quantity for the drug prescription you are requesting coverage for. Indicate whether this is a new prescription or a renewal.

Step 7 – Enter the relevant diagnosis and/or ICD-10 code into the provided field.

Step 8 – If the patient has been prescribed other therapies, enter the name, dose, route of administration, dates of therapy, and outcome for each drug prescription.

Step 9 – You must then provide any “[a]dditional significant information for requesting a non-preferred drug.”

Step 10 – Enter the date into the indicated field at the bottom of the page and print the form. Sign your name in the “Physician’s Signature” field and fax the document to the Ohio Department of Medicaid.