Pharmacy Prior Authorization and Forms

Pharmacy Prior Authorization (PA) Submission Process

If you have questions about Medicaid medication coverage or prior authorization, please contact the Pharmacy Service Line (1-800-540-6083). 

Vaya’s delegated Pharmacy Benefits Manager (PBM) reviews and makes decisions for medication requests based on medical necessity guidelines and other statutory and regulatory standards. Vaya offers an electronic portal and review system for pharmacy UM request submission, but requests may also be submitted via phone (1-800-540-6083), fax (1-855-668-8553), or U.S. mail:

Navitus Health Solutions LLC
Attn: Prior Authorizations
1025 West Navitus Drive
Appleton, WI 54913

Pharmacy UM requests are processed, and prescribers notified of the determinations, within 24 hours after receipt of the request, except for requests for which the review cannot be completed due to insufficient information. In these cases, the PBM pends the request and requests the needed information within 24 hours after receipt of the request. Once the additional information is received, the PBM completes its review within 24 hours after receipt of that information. 

Vaya allows coverage for a 72-hour supply of a medication in emergency situations where the medication could not otherwise be dispensed due to a prior authorization requirement. Vaya does not require a pharmacy to dispense this 72-hour supply if the dispensing pharmacist believes that the prescription presents a risk to the member, and if the pharmacist has made good faith efforts to contact the prescriber about it. Vaya covers consecutive 72-hour supplies if the prescriber has not completed the review or if the pharmacist has not been able to contact the prescriber to complete the requested review. 

Pharmacy PA Request Forms

The following PA Request Forms will be posted soon. 

• Antiemetic Agents
• Antinarcolepsy (Provigil and Nuvigil)
• Antinarcolepsy (Sunosi)
• Antinarcolepsy (Wakix)
• Antinarcolepsy (Xyrem and Xywaz)
• Austedo for Movement Disorders
• Cialis
• Continuous Glucose Monitors
• Crinone
• Cystic Fibrosis
• Dupixent for Asthma
• Dupixent for Atopic Dermatitis
• Dupixent for Nasal Polyps
• Emflaza
• Entresto
• Epidiolex
• Epinephrine Pens
• Evrysdi
• Exondys 51
• Fasenra
• Gattex
• Gocovri and Osmolex ER
• Growth Hormone (Adult)
• Growth Hormone (child)
• Hematinics
• Hepatitis C
• Hetlioz
• Immonomodulators
• Ingrezza for Movement Disorders
• Ivermectin
• Juxtapid
• Lupus Medications
• Medical Exceptions
• Migraine Calcitonin Gene Related Therapy
• Migraine Calcitonin Agents (Ubrelvy, Nurtec)
• Neuromuscular Blocking Agents
• Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old
• Nucala
• Opioid Analgesics (Short and Long-Acting)
• Opioid Dependence Therapy Agents
• PCSK9 Inhibitors
• Sedative Hypnotics
• Selective Constipation Agents (Relistor)
• Standard Drug Request Form
• Standard Appeal Request Form
• Synagis
• Topical Antihistamines
• Topical Anti-Inflammatory
• Topical Local Anesthetic (Lidoderm Patch, lidocaine patch, and ZT Lido)
• Triptans
• Vusion
• Xenazine and tetrabenazine for Movement Disorders
• Xolair
• Zolgensma