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Kentucky Medicaid Universal Pharmacy PA Form

Kentucky Medicaid uses one universal pharmacy prior authorization form for any drug, for both fee-for-service and managed care members, because a single state pharmacy benefit administered by MedImpact covers everyone. Prescribers meet it for non-preferred drugs, brand-medically-necessary requests, opioids and hepatitis C antivirals. Page 1 handles most drugs; opioid requests add pages 2 to 4 and hepatitis C requests add page 5.

Who completes it

The prescriber completes page 1 (member, prescriber, diagnosis, medication and prior treatments) and signs the certification; a pharmacy may also submit page 1 for some requests. Opioid requests on pages 2 to 4 must be completed by the prescriber only.

Submitting and payment

How to submit it
Fax the form with supporting documents, such as lab results and chart notes, to MedImpact at the number printed on it, checking whether the member is in managed care or fee-for-service. Telephone requests go through MedImpact's clinical call center.

Good to know

  • For a brand-medically-necessary request, the member must have tried two generic manufacturers, and samples do not count as drug trials.
  • New opioid requests ask whether the prescriber reviewed the KASPER report for the past 12 months and whether a urine drug screen was done in the past 30 days, with documentation.
  • Doses over 90 MME a day need pain or relevant specialist consultation; over 200 MME need a pain management specialist and taper documentation. Naloxone attestations also apply.
  • Hepatitis C requests need an HCV RNA viral load from the past 3 months and a FIB-4 score or cirrhosis status, which decide eligibility for simplified treatment.

Get the official form

Download the current version from the source each time; forms change without notice.

Universal Prior Authorization (PA) Form - All Drugs

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Does the Kentucky universal PA form apply to MCO members?

Yes. Kentucky moved all managed care pharmacy benefits to a single state pharmacy benefit manager in 2021, administered by MedImpact. The form has checkboxes for MCO and fee-for-service members, and the same form covers drug prior authorization for every Kentucky Medicaid member.

Which pages of the Kentucky Medicaid pharmacy PA form do I complete?

For most drugs, only page 1. For any opioid, complete pages 1 through 4, and the opioid pages must be filled out by the prescriber. For hepatitis C direct-acting antiviral therapy, complete page 1 and page 5, which also covers repeat treatment.

Are there drug-specific Kentucky Medicaid PA forms?

Only a few. Besides the universal form, MedImpact's Kentucky provider forms page lists separate forms for benzodiazepines and stimulants. Opioid and hepatitis C criteria are built into pages 2 to 5 of the universal form rather than separate forms.