Pharmacy Forms and Criteria

Prior authorization and other forms are available below.  For questions related to prior authorization or overrides, contact KEPRO at 1-800-748-0130. 


Prior Authorization Forms
Form 369 Pharmacy Prior Authorization Request - Effective 12/1/21  
Form 369 Instructions Pharmacy Prior Authorization - External Criteria - Effective 7/1/22
Form 369 Instructions Pharmacy Prior Authorization - External Criteria - Effective 4/1/21
Online PA Form For use by Health Professionals Only
Form 409 Pharmacy Override - Fillable - Effective 12/1/21
Form 412 Short Acting Opiate Naïve Days’ Supply Limit Override - fillable - Effective 12/1/21
Form 409/412 Instructions Pharmacy Override External Criteria - Effective 7/2/18
Form 413 Morphine Milligram Equivalents (MME) Cumulative Daily Override Form - Effective 12/1/21
Form 413 Instructions MME Cumulative Daily Override External Criteria - Effective 8/1/19
Form 390 Miscellaneous PA Request Form
Form 389 Opioid Dependence Treatment PA Form – Effective 12/1/21
Form 391 Opioid Dependence Treatment Agreement and Patient Consent Form - Effective 12/1/21
Form 351 Synagis® PA Request - Effective 12/1/21
Form 351 Criteria Synagis® PA Criteria - Effective 10/1/21
Form 351 - Instructions Synagis® PA Instructions Worksheet - Effective 10/1/20
Form 351 - Instructions Synagis® PA Instructions Worksheet - Effective 10/1/21
Form 351 ICD-10 Worksheet Synagis® PA Worksheet - Appendix A - ICD-10 - Effective 10/1/21
Form 470 Smoking Cessation Prior Authorization Request Form
Form 410-A Child Growth Hormone Deficiency PA Request Form
Form 410-B Child Growth Hormone/Turner, Prader-Wili, or Noonan Syndrome PA Request Form
Form 410-C Child Growth Failure/Mecasermin PA Request Form
Form 410-D Child Growth Hormone /Chronic Renal Insufficiency PA Request Form- 9/10/12
Form 411 Adult Growth Failure PA Request Form
Form 366 Growth Failure for AIDS Wasting Request PA Request Form - 12/1/21
Form 373 DMARDS/Biological Injectables PA Request Form - 12/1/21
Form 373 - Instructions Form 373 Instructions - DMARDS/Biological Injectables - 4/28/21
Form 415 Hepatitis C Antiviral Agents PA Form - Effective 12/1/21
Form 415 - Instructions Form 415 Instructions - Hepatitis C Antiviral Agents External Criteria - Effective 3/1/21
Form 392 Patient Consent Form for Hepatitis C Agents - 2/9/17
Criteria Antipsychotic Prior Authorization Criteria
Attachment A Antipsychotic Agents - Attachment A
Attachment B Antipsychotic Agents - Attachment B
Attachment C Antipsychotic Agents - Attachment C
Form Psychiatrist Specialty Notification for Prior Authorization of all Antipsychotic Drugs
Form 384 Wheelchair Seating Evaluation Form
Other Forms
Form 3500 Fillable MedWatch form from FDA for voluntary reporting of adverse events, product problems and product use errors 
Provider Notification Letter For pharmacists to use to notify primary care providers of vaccine administration - Updated 2/1/19
Form 422 Provider Compliance Referral for Tamper Resistant Prescriptions - Fillable
Contact Form Pharmaceutical Manufacturer Contact Information Form - 4/20/09
Form State Supplemental Rebate Form - 8/6/21
Form State Supplemental Rebate Form - 8/6/21  Excel Version
Forms for Recipients
Drug Denial Explanation Easy-to-Read fill-in-the-blank form that enables pharmacy to explain reason for not filling a prescription - Effective 9/1/13
Opioid Edits Easy-to-Read form that enables pharmacy staff to explain edits related to opioids.
Covered Nutritional List List of Specialized Nutritional Products - Updated 1/1/22
Nutritional Diagnosis Grid Updated 5/19/22