Try for free

Pennsylvania Medicaid Non-Preferred Medication PA Form

Pennsylvania's Department of Human Services uses this general form for fee-for-service Medical Assistance requests for a drug designated non-preferred on the Statewide Preferred Drug List. A prescriber meets it when a beneficiary needs a non-preferred medication and no class-specific form applies. The DHS Pharmacy Division reviews the medical reasons the beneficiary cannot use the preferred drugs in the same class.

Who completes it

The prescriber completes the whole form, including NPI, state license number, the drug, directions, quantity, diagnosis and ICD code, and signs it. Nursing facility residents also need the long-term care facility contact.

Submitting and payment

How to submit it
Fax the form with supporting clinical documentation, such as recent chart notes, diagnostic evaluations and lab results, to the DHS Pharmacy Division.
Who pays
The request covers fee-for-service pharmacy benefits; HealthChoices managed care members' requests go through their plan's own channels even though the PDL classes are statewide.

Good to know

  • Accepted reasons include treatment failure, intolerance, contraindication, age-specific or literature-supported indications, lack of a suitable formulation, and drug interactions with preferred drugs.
  • Answer whether the beneficiary took the non-preferred drug in the past 90 days, and submit documentation either way.
  • Renewals of previously approved drugs need documentation of tolerability and the beneficiary's clinical response.
  • DHS posts about 200 class-specific PDL fax forms plus a separate Quantity Limits/Daily Dose Limits form; check those before using this general form.

Get the official form

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

Non-Preferred Medication Prior Authorization Form

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

Where do I find whether a drug is preferred in Pennsylvania Medicaid?

The form points to the Statewide Preferred Drug List published at papdl.com, which shows preferred and non-preferred medications in each class. Prior authorization guidelines and quantity limits are on the DHS Pharmacy Services pages, and many classes have their own fax form to use instead.

What details should a treatment failure entry include?

The form asks for each preferred drug's name, dose and start and stop dates under treatment failure or inadequate response. Side effects and contraindications need a description and the drug names, and the request should attach chart or clinic notes showing those trials.