E page 1 AND page 2 of this form. For Hepatitis C Direct Acting Antiviral (DAA) Therapy or ® Requests — Complete page 1 AND page 3 of this form. For Products: o For Pain Management Diagnosis — Complete page 1 AND page 2 of this form. o For Substance Use Treatment— Please use the Kentucky Medicaid Substance Use Treatment Pharmacy Prior Authorization Form. Complete each section legibly and completely. Include any supporting documents as needed (lab results, chart notes.
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How to fill out the KY Anthem Medicaid Pharmacy Prior Authorization Form online
This guide offers clear instructions on how to complete the KY Anthem Medicaid Pharmacy Prior Authorization Form online. By following the outlined steps, users can ensure their forms are filled out accurately and submitted efficiently.
Follow the steps to successfully complete the authorization form.
- Press the ‘Get Form’ button to access the form and open it in the editor.
- Begin filling out the patient information section, which includes details such as member name, date of birth, address, and any medication allergies.
- Next, move to the prescriber information section. Here, provide the prescriber's name, NPI, contact information, and specialty, ensuring all details are correct and up-to-date.
- Fill out the diagnosis and medical information for the requested medication. Be sure to specify if it is an initial request or a reauthorization request, and include the ICD-10 code and medication details.
- If the requested medication is an opioid, continue to page 2 of the form. For Hepatitis C or ® requests, complete the additional information on pages 3 as required.
- Provide rationale for prior authorization, indicating whether the brand is medically necessary and including justification if applicable.
- Complete the section regarding previous treatments, including any previous medications, dosages, and reasons for discontinuation.
- Sign the request and date it. The information provided must be accurate and is necessary for Kentucky Medicaid to process the request.
- Review all sections of the form to ensure completeness and accuracy. After confirming the information, you can save your changes, download, print, or share the completed form.
Take the next step by completing your KY Anthem Medicaid Pharmacy Prior Authorization Form online today.
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