I. Provider Information
II. Member Information
Prescriber name (print): Member name:
Prescriber Specialty: Identification number:
Fax: Phone: Date of Birth:
Office Contact Name: Medication allergies:
III. Drug Information (One drug request per form)
Drug name and strength: Dosage form: Dosage interval (sig): Qty per Day:
Diagnosis relevant to this request:
Expected length of therapy:
Medication History for this Diagnosis
A. Is member currently treated on this medication?
yes; How Long?_______________
[go to item B]
no [skip items B & C; go to item D]
B. Is this request for continuation of a previous approval?
yes [go to item C] no [skip item C; go to item D]
C. Has strength, dosage, or quantity required per day increased or decreased?
yes [go to item D] no [skip item D; indicate rationale for continuation in Section IV and submit form]
D. Please indicate previous treatment and outcomes below.
Drug Name (include strength and dosage) Dates of Therapy Reason for Discontinuation
1
2
3
4
NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Peach State Health
Plan Preferred Drug List (PDL) is available on the Peach State Health Plan website at www.pshpgeorgia.com.
IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)
Appropriate clinical information to support the request on
the basis of medical necessity must be submitted.
Provider Signature: Date:
Minnesota Medicaid Prior Authorization Request Form for Prescriptions
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