Kentucky prior 2026

1. Click ‘Get Form’ to open the Kentucky Medicaid Pharmacy Prior Authorization Form in the editor.
2. Begin by filling out the Patient Information section. Include the member's name, date of birth, address, and sex. Ensure all fields are completed legibly.
3. Next, provide Prescriber Information. Enter the prescriber's name, NPI, address, specialty, and contact details accurately.
4. In the Diagnosis and Medical Information section, specify whether this is an initial request or a reauthorization. Fill in the diagnosis and ICD-10 code as required.
5. Complete the Medication Requested field with details about the medication including name, strength, dosage form, quantity, and expected duration of therapy.
6. If applicable, continue to page 2 for opioid requests or page 3 for Hepatitis C DAA therapy requests. Follow prompts for additional information as needed.
7. Review all entries for accuracy before submitting. Attach any necessary supporting documents like lab results if required.

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