Try for free

Iowa Medicaid 470-4108 Non-Preferred Drug PA Form

Iowa Medicaid requires prior authorization before it pays for a drug listed as non-preferred on its Preferred Drug List, and form 470-4108 is the general request for those drugs. Prescribers meet it when a patient needs a non-preferred agent after preferred ones failed or are contraindicated. A clinical consultant reviews the request for medical necessity, weighing the documented trials of preferred agents.

Who completes it

The prescriber completes the member, prescriber and pharmacy details, the drug, previous therapies with exact date ranges and the reason a non-preferred drug is needed, then signs; the signature must match the prescriber named at the top. A separate pharmacy block asks for the pharmacy NPI, fax and NDC.

Submitting and payment

How to submit it
Fax the completed form, with lab results and other documentation attached, to the Iowa Medicaid pharmacy prior authorization unit at the number printed on it. Illegible, incorrect or incomplete forms are returned.
Who pays
Approval addresses medical necessity only and does not confirm the member is still eligible for Medicaid, which the requesting provider must verify.

Good to know

  • Payment for a non-preferred drug is considered only for an FDA-approved or compendia-indicated diagnosis, with documented trial and failure of preferred agents unless they are medically contraindicated.
  • Requests for a non-preferred brand-name product go on the separate Selected Brand-Name Drugs form, not on 470-4108.
  • The request must follow FDA labeling for the drug and indication, including age, dosing, contraindications, warnings, drug interactions and use in specific populations.
  • Iowa also publishes about 116 drug-specific forms and separate forms for quantity limit overrides (470-4566), duplicate therapy (470-5460) and new-to-market drugs (470-5492).

Get the official form

Download the current version from the source each time; forms change without notice.

Request for Prior Authorization: Non-Preferred Drug

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

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 Iowa form 470-4108 instead of a drug-specific form?

Use 470-4108 for a non-preferred drug on the Iowa Medicaid Preferred Drug List when no drug-specific form covers it. Iowa publishes about 116 drug-specific forms plus forms for quantity limits, duplicate therapy and new-to-market drugs, and the 470-4108 itself sends brand-name requests to the Selected Brand-Name Drugs form.

What previous therapy details does Iowa want on 470-4108?

List each drug tried with its name, strength and exact date ranges, then explain why the non-preferred drug is needed. The form also asks for pertinent lab data, other medical conditions, possible drug interactions or conflicting therapies, and attached lab results where they support the request.