Pennsylvania Medicaid Prior Authorization Form

Updated January 23, 2022

Pennsylvania Medicaid prior authorization form is required to obtain Medicaid coverage for non-preferred drugs in the State of Pennsylvania. Filled out by a physician or pharmacist, this form must provide clinical reasoning to justify this request being made in lieu of prescribing a drug from the Preferred Drug List (PDL). For more information on prior authorization or to make a prior authorization request by phone, call the Fee-for-Service Program Pharmacy Call Center at the number provided below. If you require any further information, call the Pennsylvania Department of Human Services (DHS) Helpline at the phone numbers provided below.

Fax – 1 (866) 327-0191

Fee-for-Service Program Pharmacy Call Center # – 1 (800) 537-8862

Pennsylvania DHS Helpline # – 1 (800) 692-7462

Preferred Drug List

Specific Drug Prior Authorization Forms

How to Write

Step 1 – Download the form and open it with Adobe Acrobat or Microsoft Word.

Step 2 – Begin filling out the form by providing the following patient information:

  • Patient’s name
  • Patient’s Member number
  • Patient’s date of birth
  • Patient’s complete address
  • Line of Business (Medicaid/CHIP)

Step 3 – Next, you will need to enter all of the information listed below into the appropriate spaces.

  • Prescriber’s name
  • Prescriber’s fax and phone number
  • Prescriber’s office contact name
  • Prescriber’s NPI number
  • Prescriber’s complete address
  • Prescriber’s specialty/facility name

Step 4 – You will then be required to enter the name, strength, and directions for the requested drug. Mark if you would like this request to be expedited (using the checkbox).

Step 5 – Now, answer all of the questions listed below by using the checkboxes provided or by filling the indicated fields.

  • What is the requested duration of therapy?
  • Has the patient been treated previously with the medication?
  • Has the patient received samples of the medication?
  • Is a sample log attached including dates, dosage, and directions?
  • Has the patient received the medication through other means than above?
  • Are medical records attached showing this medication being filled?
  • Is the medication being used for a FDA approved indication?
  • What is the diagnosis? (the diagnosis paper must be attached)

Step 6 – At the top of the second page, you must re-enter the patient’s and the prescriber’s names before writing your answers to the following:

  • Has the patient tried and failed all formulary alternatives?
  • List all medications patient has been treated with previously that resulted in failure or patient intolerance
  • Are relevant labs or diagnostic test results attached?

Step 7 – If you have additional comments regarding this request, write them in the provided field.

Step 8 – Add your signature and the date where indicated.

Step 9 – Once you have finished filling out the form, print it, attach any relevant medical documents, and send all of these pages to the appropriate directory.