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Get Ky Anthem Medicaid Pharmacy Prior Authorization Form 2019

E page 1 AND page 2 of this form. For Hepatitis C Direct Acting Antiviral (DAA) Therapy or ® Requests — Complete page 1 AND page 3 of this form. For Products: o For Pain Management Diagnosis — Complete page 1 AND page 2 of this form. o For Substance Use Treatment— Please use the Kentucky Medicaid Substance Use Treatment Pharmacy Prior Authorization Form. Complete each section legibly and completely. Include any supporting documents as needed (lab results, chart notes.

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