Tennessee Medicaid Prior Authorization Form

Updated January 23, 2022

A Tennessee Medicaid Prior Authorization Form is a document used by medical offices in the State of Tennessee to request Medicaid coverage for a non-preferred drug. The person filling the form must provide medical justification as to why they are not prescribing a drug from the PDL (Preferred Drug List). Once the form has been completed, it should be submitted by fax or by mail to the directory indicated within the document.

Fax – 1 (866) 434-5523

Phone – 1 (866) 434-5524

Preferred Drug List (PDL)

How to Write

Step 1 – Download the fillable PDF version of the Medicaid PA request form and open it using Adobe Acrobat or Microsoft Word.

Step 2 – Begin filling out the form by providing the patient’s full name, ID number, and date of birth into the “Member Information” section.

Step 3 – In the “Prescriber Information” section, enter the prescriber’s full name, NPI number, DEA number, phone number, and fax number. Then, indicate if the prescriber is a TennCare provider with a Medicaid ID and if they are a single-patient contract holder for this patient.

Step 4 – In the “Requested General/Non-Preferred Drug” section, provide the name, strength, dosage form, directions, compound (Y/N), and duration of therapy of the requested drug, and indicate whether the patient may use the generic equivalent drug.

Step 5 – Next, enter the relevant diagnosis into the provided field and indicate whether the patient has failed a trial of a preferred drug. If the patient has tried any preferred drugs in treatment of this diagnosis, you must enter the name, strength, length of trial, and reason for discontinuation for each applicable drug.

Step 6 – Below that, indicate whether the patient has had an adverse effect to a preferred drug or if they are currently taking the requested medication. If you answered yes to either or both of these questions, provide the requisite additional information into the provided field.

Step 7 – If you have additional information that should be included, it should be written into the indicated space.

Step 8 – Print the completed form.

Step 9 – Provide the prescriber’s handwritten signature and the date.

Step 10 – Send the form to the correct directory.