Form FA-63: Nevada Medicaid Prior Authorization Request

Enter the DATE OF REQUEST, then under RECIPIENT INFORMATION the Last Name, First Name, Middle Initial, Date of Birth, Recipient ID, Gender (Male or Female) and Phone.

Under PRESCRIBING PROVIDER INFORMATION, enter the Name, NPI, Phone, Fax (required) and the Person to contact regarding this request.

Under DIAGNOSIS AND REQUESTED DRUG, enter the Applicable ICD-10 code and diagnosis or symptom/side effect (REQUIRED).

Enter the Name, Strength, Dosage and Duration of the requested drug. Generic substitution not permitted is a check box.

Under CLINICAL INFORMATION, explain the recipient's history of allergies or unacceptable side effects experienced with preferred (PDL) medications.

List the preferred (PDL) medications that were tried and failed for the given diagnosis, with the Drug Name, Reason for Failure and Date(s).

List any contraindications to or potential drug-drug interactions with the preferred (PDL) medications.

Enter any Additional Clinical Information (if applicable).

Check the applicable boxes to indicate each item as true for the recipient: The non-preferred drug is being requested for a unique indication that is supported by peer-reviewed literature or FDA-approved indication that is unique to the requested drug.

Check The member was recently discharged from a mental health facility on the requested medication, and enter the Date.

By signing, the prescriber certifies that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid. Enter the Prescriber's Signature and Date.

Submit fax request to: 855-455-3303. Purpose: The Nevada Medicaid Preferred Drug List (PDL) lists “preferred” drugs in specific drug categories. Prior authorization is required for non-listed drugs within these categories. Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.