Rhode Island Medicaid Prior Authorization Form

Updated January 23, 2022

Rhode Island Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug. Once completed, this form must be submitted by fax to the number found immediately below this paragraph, or by mail to the address found within the document. For more information, call the Rhode Island Department of Human Services’ Medicaid department at the phone number provided below.

Fax – 1 (401) 784-3889

Phone – 1 (401) 462-5300

Preferred Drug List – Acceptable drugs by the State

How to Write

Step 1 – Download the Rhode Island Medicaid Prior Authorization Form and open it using Adobe Acrobat or Microsoft Word.

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

  • The date
  • Client’s name
  • Client’s date of birth
  • Client’s Medicaid ID number
  • Prescriber’s name
  • Prescriber’s NPI/DEA number
  • Prescriber’s office address and phone number

Step 3 – Next, provide the requester’s name, title, phone number, and fax number into the appropriate fields.

Step 4 – Enter the name of the “Drug Requested,” the quantity, and the “Diagnosis, ICD-10 Code.”

Step 5 – If the patient has tried any preferred medication in the same class, list the name(s) and outcome(s) where indicated.

Step 6 – If you are a requesting a brand name drug, provide the name, trial dates, and outcome of any generic drugs that the patient has tried.

Step 7 – In the last field, “explain why this particular non preferred medication is medically needed for this patient.”

Step 8 – Print the form and provide your handwritten signature and the date in the indicated fields at the bottom of the page.

Step 9 – Fax this form to the correct directory.