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Pharmacy Prior Authorization

Point of Sale (POS) Pharmacy Drug Prior Authorization Instructions – (click here for instructions)

Gainwell Technologies is the MS DOM vendor for drugs billed through the POS venue. If you are a Mississippi Medicaid prescriber, please submit your prior authorization requests through the Gainwell provider web portal, or please contact the Gainwell Pharmacy PA Unit at the following:

Toll-free: 833-660-2402
Fax: 866-644-6147

 

Please utilize the drop-down menus below to select the appropriate PA packet.

Manual PA Criteria

Please utilize the appropriate PA form listed under Prior Authorization Packets in drop-down menu above. 

Manual Prior Authorization Criteria Updated
Adbry Atopic Dermatitis 11/8/2022
Akynzeo 2/3/2020
Antipsychotics 2/3/2020
Austedo 1/10/2024
CGRPs 1/1/2024
Corlanor 2/3/2020
Cresemba 2/3/2020
Dupixent – Asthma 2/3/2020
Dupixent – Atopic Dermatitis 2/3/2020
Dupixent – Eosinophilic Esophagitis 3/1/2024
Dupixent – Nasal Polyposis 12/27/2021
Dupixent – Prurigo nodularis 11/7/2022
Elevidys 2/8/2024
Emflaza 4/28/2022
Endari 2/3/2020
Eucrisa 4/1/2020
Evrysdi 1/10/2024
Exondys 2/3/2020
Farydak 2/3/2020
Fasenra 3/3/2023
Hemlibra 2/3/2020
Imcivree 2/1/2024
Ingrezza 1/10/2024
Jadenu 2/3/2020
Juxtapid 2/3/2020
Kalydeco 1/27/2021
Lotronex 2/3/2020
Lynparza 6/3/2020
Mavenclad 2/3/2020
Mayzent 2/3/2020
Ocrevus 2/3/2020
Orkambi 2/3/2020
Oxbryta 5/9/2022
Palforzia 12/16/2020
Praluent 9/12/2023
Probuphine 2/3/2020
Repatha 9/12/2023
Sivextro 2/3/2020
Stribild 2/3/2020
Sublocade 2/3/2020
Symdeko 1/27/2021
Trikafta 7/9/2021
Tybost 2/3/2020
Varubi 2/3/2020
Viltepso 1/21/2021
Vivitrol 2/3/2020
Vyepti 2/10/2021
Vyjuvek 10/27/2023
Vyondys 53 1/22/2021
Xolair – Asthma 1/1/2023
Xolair – Nasal Polyps 1/1/2023
Xolair – Urticaria 1/1/2023
Zontivity 2/3/2020
Zurzuvae 4/1/2024
Zyvox 2/3/2020

Physician Administered Drug (PAD) Prior Authorization Instructions

Telligen is currently the vendor responsible for prior authorization requests. Please click here to search the Telligen prior authorization portal.

Miscellaneous Forms

Pharmacy Reconsideration Request Form

MedWatch Form