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Nebraska Medicaid program

Prior Authorization • Prior Authorization Forms

Forms

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Prior Authorization Forms
Title
Title
Anti-Obesity Medication (Wegovy) New
Continuous Glucose Monitoring (CGM) Prior Authorization Form for Fee-for-Service (FFS) members effective May 2024 New
Documentation of Medical Necessity
Documentation of Medical Necessity for Quantity Limit or High Dose Override
Growth Hormone (GH)
Hereditary Angioedema
Hepatitis C - Effective 01/01/2024 New
Immunomodulators: Self-Administered Injectables
Insulin-like Growth Factor (IGF) for Children
Opioid Dependence Treatment Fax Form
Opioid Dependence Treatment Informed Consent Form
Psychotropics-Children