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Georgia Medicaid Fee-for-Service Multi-Ingredient Compound Drug Prior Authorization Form Fax to 888-491-9742 *****Ages 2 and under Prevacid Compound requests- please contact SXC directly for approval.

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Related content

Georgia Department of Community Health Medicaid...
Below are bullet points that may be helpful in guiding prescribers or pharmacists through...
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Georgia Department of Community Health Medicaid...
Below are bullet points that may be helpful in guiding prescribers or pharmacists through...
Learn more
Georgia Department of Community Health Medicaid...
Below are bullet points that may be helpful in guiding prescribers or pharmacists through...
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INCH-POUND GL-PD-06-05B 9 March 2015 ... - CIE Hub Dhs Form 470 0719 Hse314 Marquee MasterREV 2 .doc - Glendaleheights

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PA criteria are published on the web at .dch.georgia.gov/pharmacy →Prior Authorization Process and Criteria. Prior authorization requests and any necessary subsequent appeal should be initiated by one of the following: calling OptumRx at 1-866-525-5827 or in writing to fax number 1-888-491-9742.

Call us at 1-800-704-1484 (TTY/TDD 1-800-255-0056). You can also view more information about Peach State Health Plan in our Member Handbook. All services must be medically necessary.

The Provider Enrollment Unit can be reached at the following: Fill out the Contact Us form. Call the local number (770) 325-9600. Call the toll-free number (800) 766-4456.

*If you need help reading this information or communicating with us, ask us or call 1-877-423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).

A Georgia Medicaid prior authorization form is used by medical professionals in Georgia to request Medicaid coverage of a non-preferred drug on behalf of a patient. In addition to filling out this form, any supporting medical documentation and notes that help to justify this request must be included.

PA criteria are published on the web at .dch.georgia.gov/pharmacy →Prior Authorization Process and Criteria. Prior authorization requests and any necessary subsequent appeal should be initiated by one of the following: calling OptumRx at 1-866-525-5827 or in writing to fax number 1-888-491-9742.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232