Pharmacy Prior Authorization Forms


Pharmacy Prior Authorization Contact Information

Pharmacy Benefit Drugs (MedImpact):

KY Medicaid Universal PA Request Form – Pharmacy Benefit

Phone: (800) 210-7628

Prior Authorization Call Center: (844) 336-2676

Drug PA Fax: (858) 357-2612


Physician Administered Drugs (Passport):

Prior Authorization Pre-Service Review Guide & Request Form (Please use this form to request a PA for medically billed drugs including J Codes)

If requesting a medical benefit billed drug, please include the appropriate HCPCS code on the form.

Phone: (800) 578-0775

PAD PA Fax: (844) 802-1406