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Kentucky Medicaid Prior (Rx) Authorization Form

Kentucky Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

Kentucky Medicaid prior authorization form secures Medicaid coverage in the State of Kentucky for a medication that is not on the Preferred Drug List (PDL). It is intended for prescribing physicians and provides clinical justification as to why a PDL prescription can’t be used. On this page, you can download a fillable PDF version of this form to fill out, print, and submit via fax. For more information, call the Provider Relations telephone number provided below.

Phone – 1 (800) 807-1232

Fax – 1 (800) 365-8835

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