West Virginia's Bureau for Medical Services uses this one-page form for Medicaid pharmacy prior authorization when no drug-specific form applies. The Rational Drug Therapy Program at the WVU School of Pharmacy receives it. Because West Virginia carves pharmacy out of managed care, the form applies to all West Virginia Medicaid members, whatever their health plan.
The prescriber completes the patient, prescriber and drug details, diagnosis, previous treatment history and other pertinent information, then signs. The signature line reads prescriber or pharmacist, and the pharmacy section is filled in only if applicable.
Download the current version from the source each time; forms change without notice.
General Drug Prior Authorization Form
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No. The form's important notes state that preauthorization for medical necessity does not guarantee payment. The prescriber's signature also certifies that the request is documented in the medical record, and medical or pharmacy records must be made available on request.
Use it when a drug needs prior authorization and no drug-specific form applies. The Bureau for Medical Services posts about 125 drug-specific forms and criteria documents on its prior authorization criteria page; check there first, then use the general form.
Yes. The signature block has a checkbox for an electronic signature, and the attestation says the signature may be manual or electronic. Either way, the signer certifies medical necessity and that the request is documented in the medical records.