Prior Authorization Requests (Medicaid fee-for-service)

Prescribing providers use these forms to request prior authorization for clients enrolled in Medicaid fee-for-service. Refer to the Prior Authorization chapter for criteria information. Refer to each form's instruction page, linked below, for submission instructions.

Antiviral Agents for Hepatitis C Virus

Antiviral Agents for Hepatitis C Virus - Addendum

Cystic Fibrosis Agents (Kalydeco, Orkambi, and Symdeko) - Addendum

Emflaza - Addendum

Increlex - Addendum

Makena - Request

Makena - Addendum

OxyContin - Addendum

PCSK9 Inhibitors - Request

PCSK9 Inhibitors - Addendum

Phosphate Binders - Addendum

Synagis - Addendum

Xyrem - Addendum

Medicaid Prior Authorization Reconsideration Request