[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287423-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-287423-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","kentucky-medicaid-pharmacy-prior-authorization-form-eff09032021-final","Kentucky Medicaid Pharmacy Prior Authorization Form - eff09032021 final","","Kentucky Medicaid Pharmacy Prior Authorization Form collects required information for medication coverage decisions, including patient and prescriber details, requested drug name and dosage, quantity, days’ supply, intended duration, and directions for use. The form captures diagnosis and ICD-10 coding, prior treatment history, clinical rationale for authorization, and whether brand medication is medically necessary. It also specifies supporting documentation and fax submission to the patient’s enrolled health plan partner. Page completion requirements vary by drug category, especially opioids, Hepatitis C DAA therapy, Synagis®, and buprenorphine product pain management.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/kentucky-medicaid-pharmacy-prior-authorization-form-eff09032021-final/287423/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/kentucky-medicaid-pharmacy-prior-authorization-form-eff09032021-final/287423.png","ImageObject",442,249,{"name":42,"@type":43},"Tawan","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Which page sections must be completed for different drug request types?","Question",{"text":63,"@type":64},"Complete only page 1 for general drug requests unless otherwise noted. Opioid requests require pages 1, 2, 3, and 4; Hepatitis C DAA therapy requires pages 1 and 5; Synagis® requires pages 1 and 6. Buprenorphine pain management diagnosis requires pages 1 and 2.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What key information is required in the patient and prescriber sections?",{"text":68,"@type":64},"The form requests patient member name, address, sex, member ID, date of birth, and medication allergies, plus prescriber name, NPI, specialty, DEA, address, phone, and fax.",{"name":70,"@type":61,"acceptedAnswer":71},"What additional requirements apply to opioid prior authorization requests?",{"text":72,"@type":64},"Opioid requests require the prescriber to provide additional clinical information, including confirmation of KASPER report review and urine drug screen timing/documentation, along with details on prior non-opioid therapies, baseline risk factors, and the most recent chart or progress/clinic note. The form also notes that opioid PA requests must be completed by the prescriber only.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},287423,1789632314,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":80,"read_time":26},2336475104042,"https://ap-avatar.wpscdn.com/avatar/22000c4c32af1715be0?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786537525561427321","| 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>• For Synagis® Requests—Complete page 1 AND page 6 of this form\u003Cbr>• For Buprenorphine Products:\u003Cbr>o For Pain Management Diagnosis—Complete page 1 AND page 2 of this form.\u003Cbr>|  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Complete each section legibly and completely. Include any supporting documents as needed (lab results, chart notes, etc. ) . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Please fax completed form to the corresponding fax number of the health plan partner your patient is currently enrolled. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Plan: |  |  |  |  |  | Phone number: |  |  |  |  |  |  | Fax number: |  |\n| All Kentucky MCO Plans (Medlmpact) |  |  |  |  |  | 1 (844) 336-2676 |  |  |  |  |  |  | 1 (858) 357-2612 |  |\n| Patient Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Member Name: |  |  |  |  |  |  |  |  |  | Date of Birth: |  |  |  |  |\n| Address:\u003Cbr>City, State, Zip: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Sex: ☐Male ☐Female |  |  |  |  | Height: |  |  |  |  |  | Weight: |  |  |  |\n| Member ID: |  |  |  |  | Medication Allergies: |  |  |  |  |  |  |  |  |  |\n| Prescriber Information: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Prescriber Name: |  |  |  |  |  |  |  |  |  | NPI: |  |  |  |  |\n| Prescriber\u003Cbr>Address: City,\u003Cbr>State, Zip: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Prescriber Specialty: |  |  |  |  |  |  |  |  |  | DEA: |  |  |  |  |\n| Phone: |  |  |  |  |  |  |  |  |  | Fax: |  |  |  |  |\n| Diagnosis and Medical Information for Requested Medication: ☐ INITIAL REQUEST ☐ REAUTHORIZATION (REFILL) Request with current plan |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\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| 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 manufactures ☐Yes ☐No\u003Cbr>2) Please provide medical justification why the patient cannot be appropriately treated with the generic form of the drug.(allergy, intolerance to inactive ingredient)_____________________________________________________________________________ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Please indicate previous treatment outcomes below: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Previous Medication | Strength |  | Quantity | Directions (Sig) |  |  |  |  | Dates (from and to) |  |  | Reason for Discontinuation |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Refer to link for List of Preferred Agents:\u003Cbr>[https://kyportal. magellanmedicaid.com/public/client/static/kentucky/documents/PreferredDrugGuide_full.pdf](https://kyportal. magellanmedicaid.com/public/client/static/kentucky/documents/PreferredDrugGuide_full.pdf)\u003Cbr>☐Patient recently hospitalized\u003Cbr>If requesting antibiotics, anti-infective, antidepressants, anticonvulsants, antipsychotic for discharge to complete the course of prescription, provide duration:  (original + refills) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Additional Clinical Information or Medical Rationale for Request: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Requesting Provider: ☐ Prescriber ☐ P","cbCaiuEoyraejYTm","https://ap.wps.com/l/cbCaiuEoyraejYTm","pdf",337261,6,"English","# Prior Authorization Submission Rules\n# Patient Information\n# Prescriber Information\n# Diagnosis and Medication Details\n# Clinical Rationale and Prior Treatment History\n# Brand Medical Necessity and Supporting Documentation\n# Requesting Provider and Certification\n# Opioid-Specific Additional Requirements","[{\"question\":\"Which page sections must be completed for different drug request types?\",\"answer\":\"Complete only page 1 for general drug requests unless otherwise noted. Opioid requests require pages 1, 2, 3, and 4; Hepatitis C DAA therapy requires pages 1 and 5; Synagis® requires pages 1 and 6. Buprenorphine pain management diagnosis requires pages 1 and 2.\"},{\"question\":\"What key information is required in the patient and prescriber sections?\",\"answer\":\"The form requests patient member name, address, sex, member ID, date of birth, and medication allergies, plus prescriber name, NPI, specialty, DEA, address, phone, and fax.\"},{\"question\":\"What additional requirements apply to opioid prior authorization requests?\",\"answer\":\"Opioid requests require the prescriber to provide additional clinical information, including confirmation of KASPER report review and urine drug screen timing/documentation, along with details on prior non-opioid therapies, baseline risk factors, and the most recent chart or progress/clinic note. The form also notes that opioid PA requests must be completed by the prescriber only.\"}]","Kentucky Medicaid Pharmacy Prior Authorization Form - eff09032021 final | PDF"]