New Mexico's Office of Superintendent of Insurance publishes one uniform form for prior authorization of medical and behavioral health services, devices and prescription drugs, including formulary and step-therapy exceptions. It is a plan template: each health plan inserts its own web address, fax number and review team hours. Clinicians meet it with New Mexico commercial plans, and the state Medicaid program and Turquoise Care plans use it too.
The ordering or rendering provider, or the prescriber, completes the request sections and signs the attestation. The plan fills in the authorization number and its reviewer's name and credentials at the bottom.
Download the current version from the source each time; forms change without notice.
New Mexico Uniform Prior Authorization Form
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. The form tells requesters to skip the service sections when a drug is requested and go to the prescription drug section. That section asks for diagnosis, route, where the drug is administered, strength including loading and maintenance doses, quantity per month, anticipated start date and the rationale for any formulary or step-therapy exception.
The uniform form is the template plans customize with their own web address, fax number and review hours. OSI's utilization management page also lists Bulletin 2025-001, titled Request for Alternative Prior Authorization Form, which covers prior authorization forms other than the uniform one.
A dedicated section lists previous services or therapies, with drug, dose, duration and the reason each was discontinued plus the discontinuation date. For drug requests, it also asks for other medications used in combination with the requested drug and any known drug allergies.