Point of Sale (POS) Pharmacy Drug Prior Authorization Instructions – (click here for instructions)
Gainwell Technologies is the MS DOM vendor for Fee For Service drugs billed through the POS venue. If you are a Mississippi Medicaid prescriber, please submit your Fee For Service 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 discard all old prior authorization packets printed prior to October 1, 2022 and utilize the new forms with updated contact information located in the drop-down menu below.
For MSCAN drug prior authorizations, please click here for MSCAN plan prior authorization contact information.
Please utilize the drop-down menus below to select the appropriate PA packet.
Prior Authorization Packets
Prior Authorization Packets | Updated |
---|---|
Anti-Obesity Select Agents – Effective 10/1/2023 | 10/1/2023 |
Brand Name Multi-Source | 10/1/2023 |
Early Refill | 10/1/2023 |
Enteral Nutrition | 10/1/2023 |
EPSDT – Beneficiaries Under 21 | 10/1/2023 |
Growth Hormone | 10/1/2023 |
Hepatitis C Therapy | 10/1/2023 |
Max Unit Override | 10/1/2023 |
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) | 10/1/2023 |
Opioid Packet – Effective 8/1/2019 FAQs | 10/1/2023 |
PDL Exception Request | 10/1/2023 |
RSV-SYNAGIS® | 10/1/2023 |
Universal Prior Authorization Form | 10/1/2023 |
Manual PA Criteria
Manual Prior Authorization Criteria | Updated |
---|---|
Adbry Atopic Dermatitis | 11/8/2022 |
Akynzeo | 2/3/2020 |
Antipsychotics | 2/3/2020 |
Austedo | 6/10/2020 |
CGRPs | 11/7/2022 |
Corlanor | 2/3/2020 |
Cresemba | 2/3/2020 |
Dupixent – Asthma | 2/3/2020 |
Dupixent – Atopic Dermatitis | 2/3/2020 |
Dupixent – Eosinophilic Esophagitis | 11/30/2022 |
Dupixent – Nasal Polyposis | 12/27/2021 |
Dupixent – Prurigo nodularis | 11/7/2022 |
Emflaza | 4/28/2022 |
Endari | 2/3/2020 |
Eucrisa | 4/1/2020 |
Evrysdi | 4/6/2021 |
Exondys | 2/3/2020 |
Farydak | 2/3/2020 |
Fasenra | 3/3/2023 |
Hemlibra | 2/3/2020 |
Ingrezza | 2/3/2020 |
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 |
Sivexto | 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 |
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 |
Zyvox | 2/3/2020 |
Physician Administered Drug (PAD) Prior Authorization Instructions
Alliant Health Solutions is the current vendor responsible for prior authorization requests for fee-for-service (FFS) Medicaid beneficiaries. Please click here to direct you to the Alliant official website, or call Alliant directly at 1-888-224-3067. Providers are encouraged to register with Alliant as soon as possible to submit authorization requests via the Alliant web portal. Drug criteria may be found on the Help/Support page. For a listing of drugs that require a PA, please click one of the options below.
Miscellaneous Forms
Pharmacy Reconsideration Request Form