Pharmacy Prior Authorization Forms
The file(s) below are in PDF format (
).
- Pharmacy Prior Authorization Request Form
- Prior Authorization Pre-Service Review Guide & Request Form (Please use this form to request a PA for medically billed drugs (Jcode)
- KY Medicaid Universal PA Request Form – General
- KY Medicaid Universal PA Request form – Buprenorphine Products
Pharmacy Prior Authorization Contact Information
Passport Health Plan by Molina Healthcare
Phone: (800) 578-0775
Fax: (844) 802-1406