Skip to main content

Prior Authorization Forms & Related Info

Pharmacy Help Desk: 1-877-209-1264
Provider PA Help Desk: 1-877-207-1126

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)

MedWatch 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

Wyoming Medicaid Synagis PA Form