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Commonwealth of Kentucky

Providers • Prior Authorization

Prior Authorization

Title Last Modified
Title Last Modified
PA Request Form Brand 02/22/2013
PA Request Form Mental Health (Atypical Antipsychotic Agents Only) 02/22/2013
PA Request Form Regular (all others) 02/22/2013
PA Request Form Synagis (2012-2013) 02/22/2013
PA Request Form Suboxone/Subutex 02/03/2014
PA Request Form Zyvox 02/22/2013

For telephonic prior authorization requests or inquiries regarding a prior authorization please call (800) 477-3071.

Please fax prior authorization requests to one of the following numbers:
Regular Fax Line:800-365-8835
Urgent Requests:800-421-9064
Nursing Facility:800-453-2273
Mental Health Drugs:800-453-2273

Denials and Appeals

  • Only a patient or family member can appeal a prior authorization denial
  • The member has 30 days from receipt of the denial letter to submit a written appeal to the address below:
    • Kentucky Department for Medicaid Services
      Division of Administration and Financial Management
      Administrative Services Branch, 6W-C
      275 East Main Street
      Frankfort, KY 40621-0001
  • The prescribing physician can attend the appeal hearing and testify on the patientís behalf
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