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Virginia Medicaid Prior Authorization Form

Virginia Medicaid Prior Authorization Form

Updated July 27, 2023

A Virginia Medicaid prior authorization form is a document that a medical office submits to Provider Synergies, which handles prior authorization requests on behalf of the Department of Medical Assistance Services. The function of this form is to request for Medicaid coverage to be granted to cover a drug that does not appear on the Preferred Drug List (PDL). For more information or to make a request by phone, call the phone number provided below.

Phone – 1 (800) 932-6648

Fax to – 1 (800) 932-6651

Mail to – Provider Synergies C/O Magellan Medicaid Administration / 11013 W. Broad St / Glen Allen, VA 23060 / ATTN: MAP

Preferred Drug List