Kansas Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Kansas Medicaid prior authorization form allows a medical professional to request coverage for a drug that is not on the Preferred Drug List (PDL) on behalf of a patient who is a Medicaid member. You will need to justify your request and explain why you are not prescribing medication from the PDL. Once the form is complete, it will need to be faxed to the appropriate directory. Be sure to attach any relevant supporting medical documents along with your submission. A fillable PDF version of the Kansas Medicaid prior authorization form can be found on this page.

Preferred Drug List (PDL) – List of pre-approved drugs by the State

How to Write

Step 1 – Download the PDF version of the Kansas Medicaid prior authorization form and open it using Adobe Acrobat or Microsoft Word.

Step 2 – Begin by checking the appropriate box to indicate whether this prescription will be dispensed from a pharmacy or from your office/hospital.

Step 3 – Next, you will need to complete the “Patient Information” section by providing the patient’s name, ID number, date of birth, complete address, and phone number.

Step 4 – Beneath “Provider Information,” write your name, specialty, address, phone number, and NPI number. If applicable, enter the pharmacy name, address, and phone number. Then, enter the name, address, and phone number of the patient’s physician or facility.

Step 5 – On the next page, you will need to provide the following information regarding the drug that you are requesting coverage for:

  • Requested drug name & NDC
  • Strength/Frequency
  • Quantity
  • Day supply
  • Requested drug & HCPCS
  • Number of units requested
  • Expected length of therapy

Step 6 – Below that, you must use the checkboxes to indicate whether this is a new therapy or a renewal therapy. If this is a renewal, you will have to indicate whether the dosage is to be increased, decreased, or stay the same. Next, check the appropriate box and enter the member’s diagnosis related to this request and its ICD 10 code (if known).

Step 7 – You will then need to provide your justification for making this request. First, describe any lab and clinical data related to this request. Then, describe any other drugs the patient has taken in treatment of the relevant diagnosis. Finally, provide a clinical rationale for making this request.

Step 8 – Enter the date and print the form. Then, hand-sign your signature where indicated and submit your request by fax to the appropriate directory, including any relevant medical documentation that helps support your request.