Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Fill in the patient information section, including the member's name, date of birth, address, city, state, zip code, sex, height, weight, member ID, and any medication allergies. Ensure all information is accurate and complete.
3. Complete the prescriber information section. Include the prescriber's name, NPI, address, specialty, DEA, phone, and fax numbers.
4. Provide the diagnosis and medical information for the requested medication. Specify if this is an initial request or a reauthorization request, and include the ICD-10 code, date of diagnosis, medication requested (name, strength, dosage form), quantity, days' supply, expected duration of therapy, directions for use, and rationale for prior authorization.
5. If requested medication is a brand name, indicate if it is medically necessary and provide medical justification if applicable.
6. Include details of previous treatment outcomes, previous medication history, and reasons for discontinuation if applicable.
7. For opioid requests, continue to page 2, ensuring to provide any additional needed information and clinical rationale.
8. If the request is for Hepatitis C DAA therapy or ®, proceed to page 3 and fill in the specified information related to those medications.
9. After filling out all relevant sections, ensure your form is legible. Include any necessary supporting documents, such as lab results or chart notes as required.
10. Once completed, save your changes, then download, print, or share the form as needed. Make sure to fax the completed form to the corresponding health plan partner indicated on the form.

Start filling out your KY Anthem Medicaid Pharmacy Prior Authorization Form online today to facilitate timely access to necessary medications.