Washington Medicaid Prior Authorization Form

Updated April 02, 2022

A Washington Medicaid prior authorization form is used by medical practitioners in Washington State when they need to request Medicaid coverage for a non-preferred medication. The reason for this process is that it encourages prescribers to favor prescribing drugs that appear on the State-approved Preferred Drug List (PDL). If you require more information, call the pharmacy authorization services line at the phone number provided below.

Fax – 1 (866) 668-1214

Phone – 1 (800) 562-3022 (ext. 15483)

Preferred Drug List (PDL)

How to Write

Step 1 – Download the PDF of this form and open it with Adobe Acrobat (also compatible with Microsoft Word).

Step 2 – Enter the corresponding number to indicate whether this request is for an authorization or a request for a reimbursement rate adjustment (“512” for Pharmacy Authorization or “522” for Pharmacy Rates)

Step 3 – Indicate whether this “Authorization Type” is for an update to an existing authorization or a new request for the client.

Step 4 – Enter the patient’s full “Name,” “Client ID,” and “Reference Auth #” into the appropriate fields.

Step 5 – Beneath the “Provider Information” header, you will need to enter the following information into the indicated spaces:

  • Pharmacy NPI number
  • Pharmacy fax number
  • Prescriber NPI number
  • Prescriber specialty
  • Prescriber phone and fax number
  • Date of fill
  • Dispense as written (Y/N)

Step 6 – In the “Service Request Information” section, you will need to enter the requested drug’s name, strength, and form. Next, you will need to supply the actual per-unit cost, AWP per unit cost, prescription number, and the name of the wholesaler the drug was purchased from. Below that, enter the code qualifier, product ID number, days supply, directions for use, and product select code (1 for ‘dispense as written’, otherwise leave blank) for your requested drug(s).

Step 7 – Print your completed form and send it to the correct directory.