Under LB 77 (2025), the Nebraska Department of Insurance created this standard request that insurers and providers must accept from January 1, 2026 for prior authorization of a prescription drug or durable medical equipment. A prescriber uses it when a fully insured Nebraska plan requires approval. It goes to the insurance carrier or its pharmacy benefit manager, never to the Department.
The prescriber or ordering provider completes Sections II through VII: request type, patient, provider, drug or DME details with prior therapies, dates and a medical necessity narrative. Section I, the carrier's submission details, may already be filled in on the copy the carrier posts.
Download the current version from the source each time; forms change without notice.
Nebraska Standard Prior Authorization Request Form for Drug Benefits or Durable Medical Equipment (DME)
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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Not for fully insured plans. From January 1, 2026, all insurers and providers must accept it when a plan requires prior authorization. Carriers may post extra data needs on their websites, and the instructions advise checking those before submitting to avoid a delayed decision.
The instructions list appeals, eligibility checks, coverage verification, guarantees of payment, asking whether a service needs authorization, referrals to out-of-network providers, and prior authorization of provider-administered medication billed by the provider. Each of these goes through the carrier's other channels or the companion health care services form.
Section II has a Continuation of Care option where you enter the previous carrier's name and authorization number. The form asks you to attach the approved prior authorization details in Section VII, the clinical documentation section, together with the medical necessity narrative.