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Medicaid Forms

Below is a list of all Medicaid forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 PDF No
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 Word No
F-01674A Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa Completion Instructions DMS English 01/2017 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 Word No
F-02433A Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex, Instructions DMS English 04/2021 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis DMS English 09/2022 Word No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis DMS English 01/2023 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis DMS English 09/2022 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis DMS English 01/2023 Word No
F-02572A Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis Instructions DMS English 12/2022 PDF No
F-02572A Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis, Instructions DMS English 09/2022 PDF No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 Word No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 PDF No
F-11092A Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Instructions DMS English 07/2024 PDF No
F-02668 Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable DMS English 07/2020 PDF No
F-02668 Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable DMS English 07/2020 Word No
F-02668A Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable Instructions DMS English 07/2020 PDF No
F-00622A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Injectable Completion Instructions DMS English 07/2015 PDF No
F-00280A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Other Completion Instructions DMS English 07/2015 PDF No
F-00079A Prior Authorization/Preferred Drug List (PA/PDL) for Modafinil and Nuvigil Completion Instructions DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 Word No
F-01672A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants, Instructions DMS English 01/2022 PDF No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 PDF No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 Word No
F-11077A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Instructions DMS English 01/2022 PDF No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 Word No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 PDF No
F-00081A Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine Instructions DMS English 07/2024 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 Word No
F-01673A Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists, Instructions DMS English 04/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 Word No
F-11078A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 Word No
F-00433A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS English 05/2019 Word No
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS English 05/2019 PDF No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 Word No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 PDF No
F-13033 Probate Claims Notice DMS English 05/2021 PDF No
F-02577 Proof of In-Kind Hours DMS English 06/2023 PDF No
F-02577H Proof of In-Kind Hours, Hmong DMS Hmong 06/2023 PDF No
F-02577S Proof of In-Kind Hours, Spanish DMS Spanish 06/2023 PDF No
F-00917 Provider Enrollment Application Process DMS English 12/2013 HTML No
F-02250 Quarterly Program Integrity Report OIG English 05/2023 Excel No
F-11067 Record of Actual Daily Oxygen Use DMS English 07/2012 PDF No

Glossary

 
Last revised January 24, 2023