Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126
PA — Prior Authorization Forms
Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-866-964-3472
(Please note - If the PA form asks for supporting medical documentation, please fax this information along with the completed PA form.)
The forms are provided here in MS Word. If you cannot view a file, please download the appropriate free plug-in
from the links below.
|Wyoming Medicaid Synagis PA Form 261.75 KB||2016/10/05|
|Wyoming Medicaid Hepatitis C PA Form 370.96 KB||2016/09/01|
|Wyoming Oral Buprenorphine/Naloxone PA Form 330.25 KB||2016/07/05|
|Wyoming Medicaid Miscellaneous PA Form (01-04-2010) 259.4 KB||2016/03/18|
|Wyoming Medicaid Brand Name PA Form (5-01-2009) 158.77 KB||2013/12/18|
|MedWatch Form 692.55 KB||2009/05/07|