Forms for requesting PA for specific agents are listed below. The PA form can be opened by clicking on the form. A general prior authorization form (General Drug PA Form) can be used when a drug to be requested is neither in a category included in the Preferred Drug List nor has a specific authorization form. The forms below can be completed, printed and faxed to the Rational Drug Therapy Program or downloaded for completion and submission.

West Virginia Medicaid contracts with the West Virginia University School of Pharmacy Rational Drug Therapy Program (RDTP) for prior authorization services. Prior authorization requests can be made by faxing the appropriate PA form to 1-800-531-7787 or by electronic submission through the MediWeb Portal.

*All the forms are in .pdf format and requires Adobe Acrobat Reader to view.

• Antifungal PA Form
• COX-2 Inhibitor PA Form
• Diabetic Supply Form
• Growth Hormone PA Form (members under 21)
• Home IV Form
• PDL PA Form
• Prior Authorization Form
• Provigil, Nuvigil PA Form
• Suboxone/Subtex PA Form
• Xolair PA Form