New Hampshire requires commercial insurers and pharmacy benefit managers to use and accept this uniform form for prescription drug prior authorization requests. It was adopted under RSA 420-J:18 and the Insurance Department's Ins 2700 rules, where it appears as Appendix B. A prescriber meets it whenever a New Hampshire insurer or PBM requires approval for a medication.
The treating or prescribing provider completes Sections B through G (request type, patient, prescriber, medication, clinical information and rationale) and signs. Section A identifies the insurer or PBM and is prefilled by them.
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New Hampshire Uniform Prior Authorization Form Prescription Drug Requests
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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Yes. Under RSA 420-J:18 and Ins 2705, New Hampshire insurers and pharmacy benefit managers must use and accept the uniform form for prescription drug prior authorization requests, and they may not require information beyond what the form asks for.
Sections B through G: the type of request, patient information, prescriber information, the medication requested, clinical information and the rationale for the request, followed by the prescriber's signature. Section A, which names the insurer or PBM receiving the form, is completed by that insurer or PBM.