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.
Prior Authorization Packets
| Prior Authorization Packets | Updated |
|---|---|
| Anti-Obesity Select Agents | 7/1/2024 |
| Brand Name Multi-Source | 7/1/2024 |
| Early Refill | 7/1/2024 |
| Enteral Nutrition | 7/1/2024 |
| EPSDT – Beneficiaries Under 21 | 7/1/2024 |
| Growth Hormone | 7/1/2024 |
| Hepatitis C Therapy | 7/1/2024 |
| Max Unit Override | 7/1/2024 |
| Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) | 7/1/2024 |
| Opioid Packet – Effective 8/1/2019 FAQs | 10/1/2024 |
| PDL Exception Request | 7/1/2024 |
| RSV-SYNAGIS® | 10/15/2024 |
| Universal Prior Authorization Form | 7/1/2024 |
Manual PA Criteria
| Manual Prior Authorization Criteria | Updated |
|---|---|
| Adbry Atopic Dermatitis | 11/8/2022 |
| Akynzeo | 2/3/2020 |
| Antipsychotics | 2/3/2020 |
| Austedo | 1/10/2024 |
| CGRPs | 7/1/2024 |
| 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 | 7/12/2024 |
| 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 | 10/21/2024 |
| Orkambi | 2/3/2020 |
| 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
