Standardized One Page Pharmacy Prior Authorization Form - Mississippi Division Of Medicaid

ADVERTISEMENT

STANDARDIZED ONE PAGE PHARMACY
PRIOR AUTHORIZATION FORM
Mississippi Division of Medicaid, Pharmacy Prior Authorization Unit,
550 High St., Suite 1000, Jackson, MS 39201
☐
Magnolia Health/Envolve Pharmacy Solutions
Fax to: 1-866-399-0929
Ph: 1-866-399-0928
☐
Medicaid Fee for Service/Change Healthcare
https://
Fax to: 1-877-537-0720
Ph: 1-877-537-0722
☐
UnitedHealthcare/OptumRx
https://medicaid.ms.gov/providers/pharmacy/pharmacy-prior-authorization/
Fax to: 1-866-940-7328
Ph: 1-800-310-6826
BENEFICIARY INFORMATION
Beneficiary ID: ____ ____ ____ - ____ ____ ____ - ____ ____ ____
DOB:____ ____ /____ ____ /____ ____ ____ ____
Beneficiary Full Name:
PRESCRIBER INFORMATION
Prescriber’s NPI:
Prescriber’s Full Name:
Phone:
Prescriber’s Address:
FAX:
PHARMACY INFORMATION
Pharmacy NPI:
Pharmacy Name:
Pharmacy Phone:
Pharmacy FAX:
CLINICAL INFORMATION
Requested PA Start Date:___________________ Requested PA End Date:________________________________
Drug/Product Requested:____________________________________ Strength:__________ Quantity:_________
Days Supply:____________ RX Refills:___________ Diagnosis or ICD-10 Code(s):___________________________
☐
☐
Hospital Discharge
Additional Medical Justification Attached
Medications received through coupons and/or samples are not acceptable as justification
PLEASE COMPLETE AND FAX DRUG SPECIFIC CRITERIA/ADDITIONAL DOCUMENTATION FORM FOUND BELOW
Prescribing provider’s signature (signature and date stamps, or the signature of anyone other than the provider, are not acceptable)
I certify that all information provided is accurate and appropriately documented in the patient’s medical chart.
Signature required: ____________________________________________________________ Date: ___________________
Printed Name of Prescribing Provider:______________________________________________________________________
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

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Pharmacy Prior Authorization Form - Neighborhood Health Plan Ri Pharmacy Prior Authorization Form - Neighborhood Health Plan Ri Business
Prior Authorization Form Procrit/aranesp-florida Medicaid Prior Authorization Form Procrit/aranesp-florida Medicaid Medical
Brand Name Multi-source - Mississippi Division Of Medicaid Brand Name Multi-source - Mississippi Division Of Medicaid Medical
Specialty Pharmacy Prior Authorization Form Specialty Pharmacy Prior Authorization Form Business
Form 470 - Alabama Medicaid Pharmacy Smoking Cessation Prior Authorization Form Form 470 - Alabama Medicaid Pharmacy Smoking Cessation Prior Authorization Form Business
Pharmacy Management Request For Prior Authorization Form Pharmacy Management Request For Prior Authorization Form Medical
Prior Authorization Form (pa-16) - Molina / La. Medicaid Prior Authorization Form (pa-16) - Molina / La. Medicaid Medical
Prior Authorization Form (pa-14) Unisys / La. Medicaid Prior Authorization Form (pa-14) Unisys / La. Medicaid Medical
Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Business
Prior Authorization Form Erythropoiesis Stimulating Agents Prior Authorization Form Erythropoiesis Stimulating Agents Business

Related Categories

Parent category: Medical
Download
Go
Page of 2