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Prior authorization forms: state standard forms and payer requests

State-mandated standard prior authorization forms for drugs and services, plus the general request forms and portals of large PBMs and insurers.

Prior authorization forms ask a health plan or its pharmacy benefit manager (PBM) to approve a drug, device or service. Many states set one standard form that payers must accept. Texas has the Standard Prior Authorization Request Form for Health Care Services (NOFR001) and a drug version (NOFR002), California has form 61-211 for drugs and step-therapy exceptions, and Nebraska added standard forms from January 1, 2026. This hub lists 43 forms, from state uniform forms to the general requests of CVS Caremark, Express Scripts, Optum Rx, Aetna and others.

Send the form to the plan or PBM, not the state insurance department; Indiana and Nebraska spell this out. If a California plan does not answer a 61-211 within 72 hours (24 when exigent), the request is deemed granted; Michigan's FIS 2288 has a similar deadline. Several large payers have no national paper form: UnitedHealthcare and Anthem take medical requests in their portals, and CVS Caremark and Express Scripts prefer electronic PA. Vero Documents fills PDF forms from the visit note and the chart, and the prescriber reviews and signs.

Pharmacy benefit managers and insurers

California

Colorado

Illinois

Indiana

Iowa

Maryland

Massachusetts

Bulletin 2016-08 Form 2

Cardiac Imaging Prior Authorization Form to be used with Myocardial Perfusion Imaging (MPI); Stress Echocardiogram; Multiple Gated Acquisition Scan (MUGA); Transthoracic Echocardiogram (TTE); Transesophageal Echocardiogram (TEE)

Massachusetts standard prior authorization request for cardiac imaging studies (MPI, stress echo, MUGA, TTE, TEE).

Completed by
Ordering clinician (cardiology/primary care)
Issued by
Massachusetts Division of Insurance
Format
PDF
Language
English
Official pagePDFForm details

Michigan

Minnesota

Nebraska

New Hampshire

New Mexico

New Mexico Uniform Prior Authorization Form

Single uniform form for prior authorization of health care services and prescription drugs (including formulary and step-therapy exceptions) with New Mexico health plans.

Completed by
Ordering or rendering provider / prescriber
Issued by
New Mexico Office of Superintendent of Insurance
Format
Fillable PDF
Language
English
Official pagePDFForm details

Oregon

Texas

Washington

More US forms

MedicaidState Medicaid programs180 formsMedicareFederal34 formsInsurance companiesNational carriers128 forms

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

What is the Texas standard prior authorization form?

Texas has two. The Standard Prior Authorization Request Form for Health Care Services (NOFR001) covers services, and issuers must accept it, including Texas Medicaid and CHIP managed care organizations. The Standard Prior Authorization Request Form for Prescription Drug Benefits (NOFR002) covers drugs, devices, formulary exceptions, quantity-limit overrides and step-therapy exceptions, but not appeals. Both are faxed or mailed to the issuer or its PBM. For Medicaid fee-for-service, the service-specific TMHP forms still apply.

Do California health plans have to accept form 61-211?

Yes. The Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211) is required under California's Health and Safety Code and Insurance Code for health plans, insurers and delegated medical groups. The prescriber completes the four pages and signs the attestation on page 4, then faxes or submits it electronically to the plan named at the top. If the plan does not respond within 72 hours, or 24 hours for exigent requests, the request is deemed granted.

Which states have a uniform prescription drug prior authorization form?

In this library: California (61-211), Colorado, Illinois (3643), Massachusetts, Michigan (FIS 2288), Minnesota (C-2.0), Nebraska, New Hampshire, New Mexico, Oregon (440-4992) and Texas (NOFR002). In most of these states payers must accept the form, and many post a branded copy with their own submission details. Iowa works differently: each PBM files its single prior authorization form with the Iowa Insurance Division, which posts them.

Does UnitedHealthcare have a prior authorization form?

Not a national paper form for commercial medical services. UnitedHealthcare takes prior authorization and notification requests in the Prior Authorization and Notification tool of its Provider Portal or by EDI 278, and accepts fax only for commercial plans in Massachusetts, Nevada, New Mexico and Texas. Paper forms apply where state law mandates one. Drug requests go to Optum Rx, whose general Prior Authorization Request Form covers commercial and Medicare Part D members.