Oklahoma Medicaid Prior Authorization Form

Updated January 23, 2022

An Oklahoma Medicaid prior authorization form is a document employed by a medical office in order to request Medicaid coverage for a drug not on the State’s Preferred Drug List (PDL). We have provided a downloadable PDF version of this form on this webpage. Medicaid in the State of Oklahoma is provided by Soonercare, which is funded jointly by the federal and state government. If you require more information regarding Medicaid prior authorization, call the University of Oklahoma College of Pharmacy Pharmacy Management Consultants Prior Authorization Department at the phone number provided below.

Fax – 1 (800) 224-4014

Phone – 1 (800) 522-0114 (ext. 4)

Preferred Drug List (PDL)

How to Write

Step 1 – Download the form and open it using either the Adobe Acrobat or the Microsoft Word program.

Step 2 – Start by providing the patient’s name, member ID number, and date of birth.

Step 3 – “Section I” should be completed by the pharmacist. If this is you, provide the following information into the indicated fields of this section:

  • Pharmacy name
  • Pharmacy NPI, phone number, and fax number
  • Medication name, strength, and regimen
  • NDC number
  • Fill date
  • Prescriber name
  • Prescriber NPI, phone, and fax number

The pharmacist’s signature and the date must be provided in the appropriate spaces once the form has been printed out.

Step 4 – “Section 2” must be completed by the Health Care Provider. If you are the appropriate person, fill in the following items:

  • Diagnosis
  • Previous Tier-1 trials/OTC trails (include name, dose, length of therapy, and reason for failure)

Your signature and the date will need to be written once the form has been printed.

Step 5 – Print and sign the form.

Step 6 – Fax the completed form to the appropriate directory.