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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-02573A Prior Authorization Drug Attachment for Wakix, Instructions DMS English 04/2021 PDF No
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS English 12/2021 Word No
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS English 12/2021 PDF No
F-01430A Prior Authorization Drug Attachment for Xyrem and Xywav, Instructions DMS English 12/2021 PDF No
F-01176 Prior Authorization Fax Cover Sheet DMS English 09/2022 Word No
F-01176 Prior Authorization Fax Cover Sheet DMS English 09/2022 PDF No
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS English 07/2012 Word No
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS English 07/2012 PDF No
F-11021 Prior Authorization Request / Hearing Instrument and Audiological Services DMS English 07/2012 PDF No
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS English 05/2013 PDF No
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS English 05/2013 Word No
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS English 07/2012 Word No
F-11018 Prior Authorization Request Form (PA/RF) DMS English 05/2013 PDF No
F-11018 Prior Authorization Request Form (PA/RF) DMS English 05/2013 Word No
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS English 02/2019 PDF No
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS English 02/2019 Word No
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS English 04/2017 PDF No
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS English 04/2017 Word No
F-11083A Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA): Completion Instructions DMS English 04/2017 PDF No
F-11049 Prior Authorization/Drug Attachment (PA/DGA) DMS English 01/2024 PDF No
F-11049 Prior Authorization/Drug Attachment (PA/DGA) DMS English 01/2024 Word No
F-11049A Prior Authorization/Drug Attachment (PA/DGA), Instructions DMS English 01/2024 PDF No
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 PDF No
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 Word No
F-11054A Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA), Completion Instructions DMS English 06/2023 PDF No
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 PDF No
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 Word No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 PDF No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 Word No
F-11034A Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) Instructions DMS English 07/2022 PDF No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 PDF No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 Word No
F-11075A Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, Instructions DMS English 07/2023 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 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-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 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-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura for Atopic Dermatitis DMS English 09/2022 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

Glossary

 
Last revised January 24, 2023