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Pennsylvania Medicaid Prior Authorization Form

Pennsylvania Medicaid Prior Authorization Form

Updated July 27, 2023

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