Try for free

Delaware DMAP Medication Prior Authorization Form

Delaware Medicaid's fee-for-service pharmacy program uses this general request when a prescription needs approval: a non-preferred drug on the preferred drug list, a quantity limit override, a medical necessity override of clinical criteria, a brand name request, early or lost-medication refills, duplicate therapy, high-cost claims or a Part D override. Requests that miss any applicable criterion are denied.

Who completes it

The prescribing practitioner completes both pages: member and practitioner details, diagnosis with ICD-10 code, the drug with strength, proposed directions and duration, past and current therapy, and the justification for each request type checked.

Submitting and payment

How to submit it
Submit the request through the DMAP Provider Portal or by fax to DMAP pharmacy.
Who pays
DMAP states the form is a record for payment purposes, so the member's medical record must substantiate it, and DMAP may request chart records to confirm the information.

Good to know

  • A brand name request, and a medical necessity request based on an allergic or adverse reaction, must include a completed FDA MedWatch Form 3500.
  • For members new to Medicaid, attach a pharmacy profile, chart notes showing failed preferred drugs, or the previous physician's contact information with a non-preferred drug request.
  • Stolen or destroyed medication requests need a police or fire marshal report. Quantity limit overrides must cover other medications tried, titrations and why a lower quantity of another drug won't work.
  • Only fee-for-service members use this form; managed care members use their plan's forms. About 40 drug-specific DMAP forms cover classes such as ADHD stimulants, GLP-1 drugs and growth hormone.

Get the official form

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

Request for Medication Prior Authorization: PDL, Quantity Limit, and Medical Necessity

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 is a MedWatch form required for a Delaware Medicaid pharmacy PA?

A brand name request always needs a completed FDA MedWatch Form 3500, and so does a medical necessity request based on a documented allergic or adverse reaction. Medical necessity requests can also rest on records showing that other drugs in the same therapeutic class produced ineffective or unsafe results for the member.

Can the Delaware medication prior authorization form be used for managed care members?

No. It is the Delaware Medical Assistance Program's fee-for-service pharmacy form. Members enrolled in a managed care plan go through that plan's pharmacy prior authorization process and forms instead, so confirm the member's coverage before sending it.

Which revision of the DMAP medication PA form is current?

The two-page form shows a revision date of 10/20/2023 in its footer. It is posted in the DMAP Pharmacy Corner repository, in the Pharmacy Prior Authorization forms folder, next to the drug-specific request forms.