Brand Name Multi-Source - Mississippi Division Of Medicaid Page 2
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3PRIOR AUTHORIZATION INFORMATION
Brand-Name Multi-Source Drug / Dispense As Written (DAW)
The following brand name drugs are excluded from this requirement:
DOM designated narrow therapeutic index drugs or NTI are Coumadin, Dilantin,
Lanoxin, Synthroid, and Tegretol.
Preferred branded drugs on DOM’s PDL.
The completed FDA MedWatch form must be included with this request. A copy of the FDA
MedWatch form may be obtained online at:
Medical Necessity Prior Authorization Form for EPSDT-eligible beneficiaries
The Division of Medicaid has established a program of Early and Periodic Screening., Diagnosis,
and Treatment (EPSDT), which provides preventive and comprehensive health services for
Medicaid-eligible children and youth up to the age twenty-one (21). The service ends on the last
day of the beneficiary’s twenty-first (21
) birthday month. See MS Administrative Code, Title 23,
st
Part 223.
Reasons for prior authorization request may include, but are not limited to:
Request for more than 5 prescription claims per month
Request for more than 2 non-preferred/brand name prescription claims per month
Request for a non-preferred drug
Request for a non-covered drug
SUBMISSION AND/OR APPROVAL OF A DRUG PRIOR AUTHORIZATION REQUEST DOES NOT GUARANTEE MEDICAID PAYMENT FOR PHARMACY PRODUCTS OR THE AMOUNT OF PAYMENT.
ELIGIBILITY FOR AND PAYMENT OF MEDICAID SERVICES ARE SUBJECT TO ALL TERMS AND CONDITIONS AND LIMITATIONS OF THE MEDICAID PROGRAM.
Confidentiality Notice: This communication, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use,
disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply telephone (1-877-537-0722) or fax (1-877-537-0720) and destroy all copies of the original
message. 05/05/2017
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