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Drug Utilization Review (DUR) Board

Pharmacy and Therapeutics Committee and PDL

Prior Authorization

Medicaid/Medicare

ATTENTION

If you are a MS MEDICAID PRESCRIBER, please submit your PA requests via the Envision Web Portal for most efficient processing. https://msmedicaid.acs-inc.com/msenvision/pharmacyPriorAuthAction.do

If you are a MS MEDICAID PRESCRIBER, but are not a registered MS ENVISION WEB PORTAL USER, click here to register https://msmedicaid.acs-inc.com/msenvision/regUserSelection.do

If you are NOT a MS MEDICAID PRESCRIBER, please choose applicable PA Form below and fax your request to DOM - Pharmacy PA Unit at 1-877-537-0720.

Drug Prior Authorization Forms
Brand Oral Sr Opioid Agonists Request Form
Brand-name Antipsychotic Injection Form
Brand-Name Multi-Source Drug Request Form
Early Refill Dur Override Request Form
Maximum Unit Override Request Form
Medical Necessity Form for Children
Non-Preferred Enteral Nutrition Form
Preferred Drug List Exception Request Forms
Synagis 2011-2012 Form
Synagis Prior Authorization Criteria

Pharmacy Prior Authorization - Other Information & Forms
Appeal / Reconsideration Request Form
MedWatch Form
Process of Pharmacy PA Appeal

CIVIL RIGHTS STATEMENT

DISCLAIMER

PRIVACY AND SECURITY NOTICE

Sillers Building, 550 High Street Suite 1000, Jackson, MS 39201-1399
telephone: 601-359-6050 or toll free: 1-800-421-2408