Pharmacy Prior Authorization Forms
The file(s) below are in PDF format (
).
- Prior Authorization Pre-Service Review Guide & Request Form (Please use this form to request a PA for medically billed drugs including J Codes)
- KY Medicaid Universal PA Request Form – Pharmacy Benefit
Pharmacy Prior Authorization Contact Information
Pharmacy Benefit Drugs (MedImpact):
Phone: (800) 210-7628
Prior Authorization Call Center: (844) 336-2676
Drug PA Fax: (858) 357-2612
Physician Administered Drugs (Passport):
Phone: (800) 578-0775
PAD PA Fax: (844) 802-1406