Coverage Determination Request
The coverage determination process for prior authorization ensures that medication regimens that are high risk, have a high potential for misuse, or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.
Please select and complete the appropriate coverage determination request:
- Online Form: Request for Medicaid Prescription Drug Coverage Determination
- Medicaid Coverage Determination Request - English (PDF)
Providers may request an addition or exception for the following:
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Drugs not listed on the PDL
- Drugs that have an age edit
- Brand name drugs when a generic exists