Mississippi Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Mississippi Medicaid prior authorization form can be completed by a prescribing physician to request a medication that is not on the state’s Preferred Drug List (PDL). Mississippi Medicaid, through the managed care program Mississippi Coordinate Access Network (MississippiCAN), covers most pharmacy services through their health care plans Magnolia and UnitedHealthCare. This request form is used to ensure that the patient in question is receiving the most appropriate and cost-effective treatment available. Once the form is submitted by the physician/medical office and reviewed by the appropriate pharmacy benefit manager (PBM), the patient will receive a statement of approval or denial of the requested drug. If approved, the patient can retrieve their prescription from the appropriate pharmacy. If the request is denied, the physician may choose to prescribe a different treatment course or submit a reconsideration form.

  • 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

How to Write

Step 1 – Select the appropriate PBM at the top of the page by ticking the box next to the name of the patient’s health care plan provider.

Step 2 – In the first section, enter the beneficiary’s information including ID, DOB, and full name.

Step 3 – In the “Prescriber Information” section, enter the prescriber’s NPI, full name, phone number, address, and fax number.

Step 4 – Under “Pharmacy Information”, enter the pharmacy’s NPI, name, phone number, and fax number.

Step 5 – Next, enter the requested start date and end date of the prescription, as well as the name, strength, and quantity of the requested drug.

Step 6 – Provide how many days the supply will last, how many refills will be included, and the diagnosis or ICD-10 codes.

Step 7 – If the patient has been discharged from the hospital, tick the box on the left. If there are documents that will be attached to this form, tick the box on the right.

Step 8 – A signature is required at the bottom of the page, as well as the date and printed name of the prescriber.

Step 9 – The second page of the PA form is for information concerning the use of previous drugs that have not helped their condition and any medical reasoning relevant to the justification of prescribing the non-covered drug in question. At the top, enter again the beneficiary’s ID, DOB, and name.

Step 10 – Question (1.) of the exception criteria asks if the patient has received drugs on the PDL without success. Answer yes or no, and list the names of these drugs along with the length of therapy and reason for discontinuation.

Step 11 – Next, select yes if the patient was unable to use a preferred drug due to their condition. Select no if the above statement is false. If yes, list the problems that occurred for the patient.

Step 12 – If the reason for prescribing non-covered medication is because of a drug interaction between another medication and the preferred drugs, select yes next to question (3.) and list the interactions. Select no if this is not the case.

Step 13 – Question (4.) asks if there were side effects while on the preferred drug. Select yes or no. List the side effects if the answer was yes.

Step 14 – The prescriber must print their name and enter the date at the bottom of page 2.