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NH Medicaid Non-Preferred Drug Approval Form

New Hampshire Medicaid's fee-for-service pharmacy program uses this form when a prescriber wants a drug that is not preferred on its preferred drug list. State law (Chapter 188 of the Laws of 2004) allows coverage of non-preferred drugs only on the prescriber's finding of medical necessity, and the form's Section III lists the criteria that finding must rest on. Prime Therapeutics processes the request.

Who completes it

The prescriber completes all three sections: patient and medication requested, prescriber information with NPI and specialty, and the medical history criteria. The prescriber signs a certification that the information is accurate and complete.

Submitting and payment

How to submit it
Fax the completed form to the New Hampshire Medicaid fee-for-service pharmacy prior authorization unit run by Prime Therapeutics.
Who pays
Medicaid covers a non-preferred drug only upon a finding of medical necessity by the prescribing physician, as Chapter 188 of the Laws of 2004 requires.

Good to know

  • Accepted criteria are allergic reaction, drug interaction, prior side effect or therapeutic failure, contraindication or unique circumstance, age-specific indication, FDA or literature-supported indication, or risky therapeutic change.
  • Thirteen classes need their own PA form instead, including antihyperkinesis agents, growth hormones, hepatitis C agents, long-acting opioids, opiate dependence treatment, PPIs and systemic immunomodulators.
  • Most New Hampshire Medicaid members are in Medicaid Care Management plans, which use their own prior authorization forms rather than this fee-for-service form.
  • Section I asks for diagnosis, drug name, strength, dosing directions and length of therapy for the medication requested.

Get the official form

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

New Hampshire Medicaid Fee-for-Service Program Prior Authorization Non-Preferred Drug Approval Form

Official pagePDF

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.

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Frequently asked questions

What justification does New Hampshire Medicaid accept for a non-preferred drug?

Section III lists the criteria from Chapter 188: allergic reaction, drug-to-drug interaction, a previous unacceptable side effect or therapeutic failure, a contraindication or unique patient circumstance, an age-specific indication, an indication supported by FDA approval or peer-reviewed literature with a reference, or unacceptable clinical risk from changing therapy. Each needs supporting clinical information.

Can I use this form for a long-acting opioid or ADHD medication?

No. The form notes that antihyperkinesis agents, long-acting opioids and several other classes require separate prior authorization. Use the class-specific New Hampshire Medicaid form for those drugs, and this general form for other non-preferred drugs on the preferred drug list.