Physician certifies a participant's need for MO HealthNet personal care services.
- Completed by
- Physician
- Issued by
- Missouri Department of Social Services, MO HealthNet Division
- Format
- Fillable PDF
- Language
- English
MO HealthNet Drug Prior Authorization Form 2575-017
MO HealthNet, Missouri's Medicaid program, uses form 2575-017 as its general drug prior authorization request for drugs that hit clinical or preferred drug list edits. Prescribers meet it when a fee-for-service participant needs a drug that has no drug-specific MO HealthNet form. It records the diagnosis, the requested drug and regimen, prior medications and why alternatives were stopped or not used.
Who completes it
The prescriber's office completes the participant, diagnosis, drug and prescriber sections, and the person completing the form gives their title and credentials and signs. Every field must be supplied or the request is not processed.
Submitting and payment
- How to submit it
- Fax or mail the form to MO HealthNet's drug prior authorization unit as printed on it, or submit electronically through CyberAccess. Participants in MO HealthNet managed care plans follow their plan's pharmacy process.
Good to know
- If a generic is available and the request is for the brand, use the Request for Brand Name Drug Prior Authorization form (2575-022) instead.
- The diagnosis must be consistent with a medically accepted use, with an ICD-10 code and the date it was established.
- For physician-administered drugs, give the 11-digit NDC; list all previously tried medications with dose, schedule and length of use.
- Mark the request as initial or renewal, and give the date the drug was first used and the expected duration of need. The current version is dated October 2024.
Get the official form
Download the current version from the source each time; forms change without notice.
Drug Prior Authorization
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
When should I use a drug-specific MO HealthNet form instead of 2575-017?
MO HealthNet posts about 14 drug-specific forms, including opioids (2575-021), benzodiazepines (2575-054), hepatitis C (2575-048), targeted immune modulators (2575-010), brand name drugs (2575-022) and GLP-1 agonists. Use 2575-017 for drugs requiring prior authorization that none of those forms covers.
Why does the MO HealthNet drug PA link show a notice instead of a PDF?
The Missouri Department of Social Services serves its fillable PDFs through a viewer page and asks users to download the form to use its fillable fields. Save the PDF, complete it in a PDF reader, then fax or mail it.