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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.
- MS Word Viewer (.doc or .rtf)
- MS Excel Viewer (.xls)
- Acrobat Viewer (.pdf)
| File | Description | Date |
|---|---|---|
| Wyoming Medicaid Synagis PA Form 249.95 KB | 2023/10/31 | |
| Wyoming Oral Buprenorphine/Naloxone PA Form 216.82 KB | 2023/06/30 | |
| Wyoming Narcotic and Tramadol Prior Authorization Form 236.63 KB | 2022/09/30 | |
| Wyoming JCode PA Form 143.45 KB | 2021/11/30 | |
| Wyoming Medicaid Hepatitis C PA Form 241.46 KB | 2019/11/26 | |
| Wyoming Adult ADHD PA Form 150.25 KB | 2019/07/10 | |
| Wyoming Medicaid Client Disclosure and Commitment to Take Hepatitis C Medication form 292.97 KB | 2018/09/26 | |
| Wyoming Medicaid Brand Name PA Form (5-01-2009) 217.04 KB | 2018/02/05 | |
| Wyoming Medicaid Miscellaneous PA Form (01-04-2010) 193.58 KB | 2018/02/05 | |
| MedWatch Form 214.15 KB | 2018/02/05 |
Additional PA News & Info
| File | Description | Date |
|---|---|---|
| WYOMING MEDICAID PROVIDER PORTAL REGISTRATION PROCESS 60.78 KB | 2020/01/21 | |
| 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 |