West Virginia Medicaid Prior (Rx) Authorization Form

Updated January 24, 2022

West Virginia Medicaid prior authorization form is completed and filed by a doctor who believes it’s medically necessary to prescribe a non-preferred drug to a patient. The physician has to justify their medical reasoning for prescribing a drug not included in the PDL. There is an established preferred drug list (PDL) that physicians must refer to when prescribing medication to their patients. The goal of the West Virginia Medicaid program is to make sure medications prescribed by registered providers are appropriate for the patient to whom the medication is being prescribed. The Drug Utilization Review Board makes the final decision on all prior authorization form submissions and even if the medical reasoning is sound, it’s possible that the request may be denied.

Form can be faxed to: 1 (800) 531-7787

Phone number: 1 (800) 847-3859

Preferred Drug List

How to Write

Step 1 – Enter the patient’s full name as well as their Medicaid number and date of birth.

Step 2 – Enter the prescribing physician’s full name, address, NPI number, phone number, and fax number.

Step 3 – Provide the name of the pharmacy along with the address, NPI number, phone number, and fax number.

Step 4 – The next section is where information pertaining to the requested drug will be entered. Provide the name of the drug, the strength, type of administration, directions for administration, diagnosis, and the ICD code.

Step 5 – Below the drug information, provide a treatment history for the patient in question. This will include any previous drugs that have been used to treat the patient’s condition and why these medications failed. Any other information pertaining to the patient, their condition, or the drug being requested can be added in the “Other Pertinent Information” section.

Step 6 – The prescriber or pharmacist must sign at the bottom and enter today’s date.