Brand Name Multi-Source - Mississippi Division Of Medicaid Page 3
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3CRITERIA/ADDITIONAL DOCUMENTATION
BRAND NAME MULTI-SOURCE DRUG
BENEFICIARY INFORMATION
Beneficiary ID:____ ____ ____ - ____ ____ ____ - ____ ____ ____
DOB:____ ____ /____ ____ /____ ____ ____ ____
Beneficiary Full Name:
Brand Name Multi-Source Drug / Dispense As Written (DAW) Criteria
MS Division of Medicaid requires that all information requested on this form be completed for consideration of approval
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:
DOCUMENTATION OF TRIAL OF GENERIC PRODUCT
Generic Product:________________
Manufacturer:_____________________
Length of Therapy:___________________
Observed adverse reaction or allergic reaction:_________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Documentation Included:
Yes
No
Generic Product:________________
Manufacturer:_____________________
Length of Therapy:__________________
Observed adverse reaction or allergic reaction:________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Documentation Included:
Yes
No
Has a completed FDA MedWatch form been submitted to the FDA?
Yes
No
Printed Name of Prescribing Provider:___________________________________________ Date:__________________________________
FAX THIS PAGE
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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