[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288924-105":53,"doc-detail-288924-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","kentucky-medicaid-pharmacy-prior-authorization-form-drug-requests","Kentucky Medicaid Pharmacy Prior Authorization Form - Drug Requests","","Kentucky Medicaid Pharmacy Prior Authorization Form for drug requests collects member, prescriber, and pharmacy information and requires completion of diagnosis and medical details tied to the requested medication. The form supports initial requests, reauthorization/refills, and special workflows for opioids and hepatitis C direct acting antiviral (DAA) therapy. It captures medication specifics, dosing directions, quantity, therapy duration, rationale, brand-necessity questions, prior treatment outcomes, and required supporting documentation.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/kentucky-medicaid-pharmacy-prior-authorization-form-drug-requests/288924/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/kentucky-medicaid-pharmacy-prior-authorization-form-drug-requests/288924.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Vance","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Which page(s) must be completed for opioid requests and hepatitis C DAA therapy?","Question",{"text":108,"@type":109},"Complete page 1, 2, 3, and page 4 for all opioid requests. For hepatitis C DAA therapy, complete page 1 and page 5.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for member and prescriber sections?",{"text":113,"@type":109},"The form requests member name, date of birth, address, sex, member ID, and medication allergies, along with prescriber name, NPI, specialty, address, and contact details.",{"name":115,"@type":106,"acceptedAnswer":116},"When is brand medically necessary documentation needed?",{"text":117,"@type":109},"Select whether the requested brand medication is medically necessary. If yes, answer the brand-related questions, including whether the member tried two generic manufacturers and provide justification for why the generic form cannot be used.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288924,1790299671,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},549768064622,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","| Kentucky Medicaid Pharmacy Prior Authorization Form\u003Cbr>• For Drug Requests (unless noted below)—Complete ONLY page 1 of this form.\u003Cbr>• For ALL Opioid Requests—Complete page 1, 2,3 AND page 4 of this form.\u003Cbr>• For Hepatitis C Direct Acting Antiviral (DAA) Therapy—Complete page 1 AND page 5 of this form.\u003Cbr>|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Complete each section legibly and completely. Include any supporting documents as needed (lab results, chart notes, etc. ) . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Plan: |  |  |  |  |  | Phone number: |  |  |  |  |  |  | Fax number: |  |\n| ☐ MCO Member |  |  |  |  |  | (844) 336-2676 |  |  |  |  |  |  | (858) 357-2612 |  |\n| ☐ FFS Member |  |  |  |  |  | (877) 403-6034 |  |  |  |  |  |  |  |  |\n| Member Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Member Name: |  |  |  |  |  |  |  |  |  | Date of Birth: |  |  |  |  |\n| Address:\u003Cbr>City, State, Zip: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Sex: |  |  |  |  | Height: |  |  |  |  |  | Weight: |  |  |  |\n| Member ID: |  |  |  |  | Medication Allergies: |  |  |  |  |  |  |  |  |  |\n| Prescriber Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Prescriber Name: |  |  |  |  |  |  |  |  |  | NPI: |  |  |  |  |\n| Prescriber Address:\u003Cbr>City, State, Zip: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Prescriber Specialty: |  |  |  |  |  |  |  |  |  | DEA: |  |  |  |  |\n| Phone: |  |  |  |  |  |  |  |  |  | Fax: |  |  |  |  |\n| Pharmacy Information (If this request is made by the pharmacy) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Pharmacy Name: |  |  |  |  |  |  |  | NPI: |  |  |  |  |  |  |\n| Phone: |  |  |  |  |  |  |  | Fax: |  |  |  |  |  |  |\n| Diagnosis and Medical Information for Requested Medication: ☐ INITIAL REQUEST ☐ REAUTHORIZATION (REFILL) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Diagnosis: |  |  |  |  |  |  | ICD-10 Code: |  |  |  |  |  |  | Date of Diagnosis: |\n| Medication Requested (name, strength, and dosage form):\u003Cbr>If request is for an opioid, please continue to page 2. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Quantity: |  | Days’ Supply: |  |  |  |  |  |  | Expected Duration of Therapy: |  |  |  |  |  |\n| Directions for Use: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| ☐Continuation of Care from recent hospitalization\u003Cbr>If requesting antibiotics, anti-infective, antidepressants, anticonvulsants, antipsychotic for discharge to complete the course of prescription, provide duration:  (original + refills) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Rationale for Prior Authorization: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Brand Medically Necessary? ☐Yes ☐No If yes, please answer the following questions:\u003Cbr>1) Has the member tried 2 generic manufacturers: Samples do not count as drug trials ☐Yes ☐No\u003Cbr>2) Please provide medical justification why the member cannot be appropriately treated with the generic form of the drug (allergy, intolerance to inactive ingredient)_____________________________________________________________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Pharmacy Coverage vs Medical: ** Medical Coverage FFS Contact Gainwell at 800-807-1232** |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Request override for Pharmacy Coverage vs Medical? ☐Yes ☐No If yes, please answer the following questions:\u003Cbr>1) Does the prescriber attend medication is being self-administered AND appropriate per dosage and administration section of the package insert?\u003Cbr>☐Yes ☐No\u003Cbr>2) Is the medication being administered by a home infusion provider? ☐Yes ☐No\u003Cbr>3) Is the medication being used for a compound in compliance with USP 795, or 797, standards for compounding? ☐Yes ☐No |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Please indicate previous treatment outcomes below: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Previous Medication | Strength |  | Quantity | Direct","cbCairGomqbhFUqy","https://ap.wps.com/l/cbCairGomqbhFUqy","pdf",412764,"English","# Member Information\n## Prescriber Information\n## Pharmacy Information\n# Diagnosis and Medical Information\n## Requested Medication and Therapy Details\n## Rationale for Prior Authorization\n## Brand Medically Necessary Questions\n# Prior Treatment Outcomes\n# Requesting Provider and Certification","[{\"question\":\"Which page(s) must be completed for opioid requests and hepatitis C DAA therapy?\",\"answer\":\"Complete page 1, 2, 3, and page 4 for all opioid requests. For hepatitis C DAA therapy, complete page 1 and page 5.\"},{\"question\":\"What information is required for member and prescriber sections?\",\"answer\":\"The form requests member name, date of birth, address, sex, member ID, and medication allergies, along with prescriber name, NPI, specialty, address, and contact details.\"},{\"question\":\"When is brand medically necessary documentation needed?\",\"answer\":\"Select whether the requested brand medication is medically necessary. If yes, answer the brand-related questions, including whether the member tried two generic manufacturers and provide justification for why the generic form cannot be used.\"}]","Kentucky Medicaid Pharmacy Prior Authorization Form - Drug Requests | PDF",1789634231]