Wyoming Medicaid Prior (Rx) Authorization Form

Updated January 24, 2022

A Wyoming Medicaid prior authorization form is completed by a physician who wishes to prescribe a drug that is not on the preferred drug list (PDL) and submitted to the Wyoming Drug Utilization Review Board. When treating a patient, Medicaid providers in Wyoming are encouraged to prescribe medication found on the Wyoming Department of Health’s PDL. Once submitted, the request will be evaluated by the board and will only be approved if they deem it medically necessary. It’s up to the prescribing physician to rationalize their decision by providing medical reasoning for their choice of medication. Any documents that support their explanation should be attached to the request form. If the request is denied, the patient may choose to pay for this medication out of pocket or appeal the prior authorization.

Form can be faxed to: 1 (866) 964-3472

Phone number: 1 (877) 207-1126

Preferred Drug List

How to Write

Step 1 – The first section of the prior authorization form must be complete with client’s  ID number, name, and date of birth; prescriber’s NPI number, name, phone number, address, and fax number; and pharmacy’s NPI number, name, and phone number.

Step 2 – Enter the name of the drug being requested along with the strength, dosage instructions, supply, quantity, and refills (if applicable).

Step 3 – If the request is for a dose/quantity change, select “Yes”. Otherwise select “No”.

Step 4 – If the previous PA can be cancelled, select “Yes”. Otherwise select “No”.

Step 5 – Provide the diagnosis for the patient in question.

Step 6 – Include the medical reasoning in terms of the necessity of prescribing the requested drug over other options.

Step 7 – The next section requests that all previous medications that were prescribed to the patient for their condition be provided along with their dates of use and the reason for termination. Below that, an explanation is required as to why similar medication that is on the PDL has not been prescribed and why they are not suitable for the patient.

Step 8 – The prescriber must sign at the bottom and include the date of submission.