Illinois Medicaid's uniform pharmacy prior authorization request covers drugs billed through the pharmacy benefit and physician-administered drugs billed to the medical benefit. Fee-for-service Medicaid and every HealthChoice Illinois managed care plan accept it, so prescribers use one form whatever the patient's plan and fax it to that plan's pharmacy benefit manager. HFS brought the form to a Uniform Prior Authorization Form Committee vote in 2022.
The prescriber completes the form and signs the representation in section F; every prescriber must be enrolled in the Medicaid Prescribers IMPACT system. When a pharmacy is the requesting provider, it also completes section E with its name, fax and optional NPI.
Check initial authorization or renewal. Then mark whether the drug is billed through the pharmacy benefit, the medical benefit as a physician-administered drug, or unknown. The form asks submitters to make sure the request is faxed to the correct department for that benefit. Before starting, it directs prescribers to the current preferred drug list to check for preferred alternatives.
Enter the patient's name, date of birth, MCO if applicable, and the nine-digit health plan member ID, which is required. Note whether the patient is hospitalized and, if so, the discharge date. A box is provided for a provider stamp if desired. The patient's name and member ID repeat at the foot of both pages.
Give the prescriber's name, NPI and specialty, a contact name, contact phone and fax, an optional email and the pharmacy phone. The form states that all prescribers must be enrolled in the Medicaid Prescribers IMPACT system. Plans may need to follow up with the prescriber for drug-specific information, so the contact details should reach someone who can answer clinical questions.
Section E is required only when the pharmacy is the requesting provider: pharmacy name, fax and optional NPI. In section F the provider represents that the information is true, complete and fully disclosed, with a warning that giving false or deceptive information with intent to defraud may be insurance fraud. The provider then prints their name, signs and dates.
Page 2 records the drug name, strength, dosage form, quantity, day supply, dosing frequency, duration of therapy, NDC if available, the start date of this request, a specific diagnosis and its ICD-10 code. Note whether the patient has already started the drug and when. For physician-administered drugs, add the HCPCS code, place of infusion or injection and facility provider or TIN. For additional drugs, attach another copy of this page.
Summarize the history of present illness, past medical history and current medications, and attach chart notes to support the request. The form reminds Medicaid providers to use equally effective, cost-saving preferred agents whenever possible, and states that previous medications used must be reflected in paid pharmacy claims.
For each failed or contraindicated therapy, give the drug name, strength, dosing schedule, duration and the reason for discontinuation or contraindication. Section J asks whether any current medications for this indication will be stopped if the requested drug is approved, and to list them.
State the specific goals of therapy and expected clinical benefit, with relevant diagnostic labs, measures and response to treatment. Section L warns that certain drugs need supplemental information described on the plan's website, that a form with insufficient clinical information may face an extended review or an adverse determination, and that plans may follow up with the prescriber.
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Illinois Medicaid Pharmacy 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.
Sources for this guide
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Yes. It is the uniform form accepted by Illinois Medicaid fee-for-service and every HealthChoice Illinois managed care organization through its pharmacy benefit manager. Page 1 lists each plan's PBM with its fax number, so the request goes straight to the patient's own plan, and section C asks for the MCO name when one applies.
Yes. HFS says that, depending on the drug, either the prescribing physician or the dispensing pharmacist may request prior approval. When the pharmacy is the requesting provider, section E is required with the pharmacy's name and fax, and its NPI is optional. Section D must still identify the prescriber, who has to be enrolled in IMPACT.
Sections H to K ask for the rationale (history of present illness, past medical history, current medications), failed or contraindicated therapies with drug, strength, schedule, duration and reason stopped, current medications that will be discontinued, and goals of therapy with relevant labs and response to treatment. Attach chart notes, and check the plan's website for drug-specific requirements.
No. HFS 1409 is the general fee-for-service prior approval request for equipment, supplies and services, and its instructions send medication requests to the pharmacy forms. HFS 1409X is the pharmacy form for drugs billed through the pharmacy benefit or as physician-administered drugs, and every HealthChoice Illinois plan accepts it as well as fee-for-service.