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Missouri Medicaid Prior (Rx) Authorization Form

Missouri Medicaid prior authorization form is a document used by a prescribing healthcare provider to obtain Medicaid coverage for a non-preferred drug on behalf of a patient. Submitting this form is required when a doctor wishes to treat a Medicaid patient with a medication that is not on the state-approved preferred drug list.
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  • Department of Social Services (DSS) MO HealthNet Division phone number: 1 (800) 392-8030
  • Form can be faxed to: 1 (573)636-6470
  • Form can be mailed to:
    ATTN: Drug Prior Authorization
    MO HealthNet Division
    P.O. Box 4900
    Jefferson City, MO
    65102-4900