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Virginia Medicaid Prior Authorization Form

A Virginia Medicaid prior authorization form is a document used by a healthcare provider or medical office to request Medicaid coverage for a prescribed medication that does not appear on the preferred drug list. When submitting the form, the prescribing physician must provide the medical justification for treating their patient with a non-preferred drug.
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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