The forms in this section are used for prescribing providers to request prior authorization for clients enrolled in Medicaid fee-for-service. Refer to the Prior Authorization chapter for general criteria information. Refer to each form's instruction page for requirements and submission instructions.

Antiviral Agents for Hepatitis C Virus - Initial Request

Antiviral Agents for Hepatitis C Virus - Initial Request - Addendum

Cystic Fibrosis Agents (Kalydeco/Orkambi/Symdeko) - Addendum

Emflaza - Addendum

Increlex - Addendum

Makena - Request

Makena - Addendum

OxyContin - Addendum

PCSK9 Inhibitors - Request

PCSK9 Inhibitors - Addendum

Phosphate Binders - Addendum

Synagis - Addendum

Xenical - Request

Xenical - Addendum

Xyrem - Addendum

Medicaid Prior Authorization Reconsideration Request