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Pharmacy Resources

Below are resources and links for pharmacy services.

Pharmacy Forms

Title File Name Caption Date
DOMPriorAuthorizationInstructions DOMPriorAuthorizationInstructions.pdf April 8, 2014 8:31 pm
MedWatch Form MedWatch-Form.pdf April 8, 2014 8:47 pm
Pharmacy Notification of Other Insurance Coverage Pharmacy-Notification-of-Other-Insurance-Coverage.pdf April 8, 2014 8:48 pm
Pharmacy Appeal/Reconsideration Form Request PharmacyAppealReconsiderationRequestForm.pdf April 8, 2014 8:48 pm
Synagis Season 2012-2013 in Mississippi Synagis-2010-2011-PA-Criteria.pdf April 8, 2014 8:48 pm
Crossover Form B CrossoverFormB.pdf April 8, 2014 8:48 pm
Pharmacy Claim Form and Form Instructions MedicaidTitleXIXPharmacyInvoice.pdf April 8, 2014 8:48 pm
PriorAuthorizationForm PriorAuthorizationForm.pdf December 18, 2014 8:02 pm
Synagis PA criteria 2015-2016 2015-2016-synagis-criteria.pdf September 10, 2015 6:33 pm
Antipsychotics Manual PA form Antipsychotics-Manual-PA-form.pdf August 29, 2016 12:58 pm

*Main Forms webpage

90-Day Maintenance Lists

Over-the-Counter Drug Lists

Specific Drugs

Billing and Claims

Other

Helpful Links