Kentucky Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

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

How to Write

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

Step 2 – Begin filling out the form by providing the full name, ID number, date of birth, and gender of your patient into the “Member Information” section.

Step 3 – Next, beneath “Prescriber Information,” provide your full name, NPI number, DEA number, phone number, fax number, and specialty.

Step 4 – If applicable, enter the pharmacy name, NPI number, phone number, and fax number into the indicated fields of the “Pharmacy Information” section.

Step 5 – In the “Request” section, you will need to provide the following information regarding the drug that you are requesting coverage for:

  • Drug name
  • Strength
  • Dosage form
  • Primary diagnosis
  • Dosage schedule
  • Other diagnoses
  • Quantity
  • Day supply

Step 6 – In the “Rationale for Prior Authorization” section, you will need to enter the “Requested Start Date” in the indicated space. Then, describe any current medications that the patient is using in the “Current Medications” field. Next, in the “Medical Justification” section, describe any other drugs they have been prescribed in the treatment of the relevant diagnosis (including trial dates) and provide your medical justification for making this request.

Step 7 – Enter the date where indicated and print the completed form. Provide your handwritten signature where indicated and submit your request via fax to the appropriate directory.