Prior Authorization Forms & Related Info | Wyoming Medicaid

Providers: Please submit completed PA forms to the Optum prior authorization team via fax at 1-866-964-3472

Please select the desired PDF from the options provided below.

If you cannot view a file, please download the appropriate free plug-in: Acrobat Viewer (.pdf)

Sublocade PA Form

Wyoming Medicaid Adult ADHD PA Form

Wyoming Medicaid Brand Name PA Form

Wyoming Medicaid Client Disclose and Commitment to Take Hepatitis C Form

Wyoming Medicaid Hepatitis C PA Form

Wyoming Medicaid JCode PA Form

Wyoming Medicaid Miscellaneous PA Form

Wyoming Medicaid Narcotic and Tramadol PA Form

Wyoming Medicaid Oral Buprenorphine_Naloxone PA Form

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