Connecticut's Department of Social Services uses this general pharmacy prior authorization request for HUSKY Health drugs and products, reviewed by Gainwell Technologies. A prescriber meets it when a pharmacy claim needs approval for a brand medically necessary request, an early refill, a non-preferred drug on the preferred drug list, or an optimal dose exception for more than once-daily dosing.
Only the prescribing practitioner completes and signs the form; an agent's signature is not accepted, and pharmacies may not send prescribers pre-signed forms or handle the request for them.
Download the current version from the source each time; forms change without notice.
Drug/Product Prior Authorization Request Form
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.
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Only the prescriber. The signature is mandatory and others may not sign for the prescriber. Requests must originate with the prescriber, and pharmacies should not ask for or submit pre-signed forms. By signing, the prescriber also certifies that the patient is under the practice's ongoing care.
Up to 6 months from the date of fill for controlled medications and up to 1 year for non-controlled medications and products. Early refill authorizations are one-time approvals, and a vacation supply early refill can be granted only once per medication every six months.
Only the section for the type of request: 13 for brand medically necessary, 14 for an early refill, 15 for a non-preferred drug or product, or 16 for an optimal dose request. Incomplete requests are denied, so give trial lengths, dates and chart details in the chosen section.