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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 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.

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

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.

  • To determine whether Physician Administered Drugs require PA by Alliant, follow this link and search by procedure code:
    • Please note: This searchable procedure code PA listing includes all code types, not just drug codes.

Miscellaneous Forms

Pharmacy Reconsideration Request Form

MedWatch Form