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:

  1. Select and print the proper form from the list below
  2. Fill out the form completely
  3. 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.

File Description Date
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

Additional PA News & Info

File Description Date
Additional Therapeutic Criteria Effective 01-01-2014 56.92 KB 2013/12/30
Additional Therapeutic Criteria 56.32 KB 2013/10/14

Prior Authorization Process

File Description Date
Website PA Process 167.99 KB 2010/08/06