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Mississippi Medicaid Prior (Rx) Authorization Form

Mississippi Medicaid prior authorization form is completed and submitted by a prescribing physician to request that a medication that is not on the state's preferred drug list (PDL) receive Medicaid coverage. The request form is used to ensure that the patient in question is receiving the most appropriate and cost-effective treatment available.
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  • Medicaid Fee-for-Service/Change Healthcare
    • Fax number: 1 (877) 537-3720
    • Phone number: 1 (877) 537-0722
  • Magnolia Health/Envolve Pharmacy Solutions
    • Fax number: 1 (866) 399-0929
    • Phone number: 1 (866) 399-0928
  • UnitedHealthCare/OptumRx
    • Fax number: 1 (866) 940-7328
    • Phone number: 1 (800) 310-6826