Virginia Medicaid Prior Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Download the Virginia Medicaid prior authorization form and open it using Adobe Acrobat or Microsoft Word.

Step 2 – Enter “Today’s Date” and the “Requested Start Date.”

Step 3 – In the “Patient Information” section, enter the following information:

  • Patient’s full name
  • Patient’s Medicaid ID number
  • Patient’s date of birth
  • Patient’s gender

Step 4 – Beneath “Drug Information,” enter the information listed below into the indicated fields.

  • Drug name/Form
  • Diagnosis
  • Strength/Dosage
  • Length of therapy

Step 5 – Next, select any of the following justifications which apply to your patient’s case, providing a written explanation for each applicable case:

  • Allergy to medications
  • Contraindication to medications
  • Drug-to Drug Interaction to medications
  • Unacceptable/toxic side effect to medications
  • Therapeutic failure to medications
  • Patient’s condition is clinically stable and changing to a medication may cause deterioration of the patient’s conditions
  • Other clinical rationale to support use of the requested medication

Step 6 – In the “Prescriber Information” section, enter the prescriber’s name, NPI number, phone number, fax number, and their signature.

Step 7 – Once completed, print and sign the form.

Step 8 – Send the completed form to the correct directory.