Fillable General Prior Authorization Form 855-207-0250 For questions regarding

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General Prior Authorization Form 855-207-0250 For questions regarding

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General
Prior Authorization Form
Fax Completed Form to:
855-207-0250
For questions regarding this
Prior authorization, call
866-773-0695
ND Medicaid requires that patients receiving a prescription for non-preferred medications to meet specific diagnosis and
step-therapy requirements. Criteria for agents requiring prior authorization can be found at one of the following locations:
• The Preferred Drug List (PDL) available at www.hidesigns.com/assets/files/ndmedicaid/NDPDL.pdf
• Prior Authorization Criteria available at www.hidesigns.com/assets/files/ndmedicaid/2018/Criteria/PA_Criteria.pdf
***Completed Medwatch form(s) must be attached to this request for failed trial(s) in which the active ingredient of
the failed product is the same as the requested product***
Part I: TO BE COMPLETED BY PHYSICIAN
Recipient Name
Recipient Date of Birth
Recipient Medicaid ID Number
Prescriber Name
Specialist involved in therapy (if not treating physician)
Prescriber NPI
Telephone Number
Fax Number
Address
City
State
Requested Drug and Dosage:
Diagnosis for this request:
List all failed medications:
Start Date:
Additional Qualifications for Coverage (e.g. medical justification explaining inability to meet required trials)
□ Patient is pregnant: Due Date ___________________
□ Patient has inability to take or tolerate solid oral dosage forms (please attach swallow study)
□ Patient has feeding tube in place: (please state specific type of feeding tube ______________________)
□ Other: (please fill out below)
□ I confirm that I have considered a generic or other alternative and that the requested drug is expected to result in the
successful medical management of the recipient.
Prescriber (or Staff) / Pharmacy Signature**
Date
**: By completing this form, I hereby certify that the above request is true, accurate and complete. That the request is
medically necessary, does not exceed the medical needs of the member, and is clinically supported in the patient’s
medical records. I also understand that any misrepresentations or concealment of any information requested in the prior
authorization request may subject me to audit and recoupment.
Part II: TO BE COMPLETED BY PHARMACY
PHARMACY NAME:
ND MEDICAID PROVIDER NUMBER:
TELEPHONE NUMBER
FAX NUMBER
DRUG
NDC #
Prior Authorization Vendor for ND
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General Prior Authorization Form 855-207-0250 For questions regarding

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Completed 7 June 2021

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