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Alaska Medicaid / Prior Authorization Request Form Prescriber Use Only Fax this request to 888 603-7696 Questions Call Magellan Medicaid Administration at 800 331-4475 Or mail this request to Medicaid PA Unit 14100 Magellan Plaza Maryland Heights MO 63043 Form available http //dhss. alaska*gov/dhcs/Pages/pharmacy/medpriorauthoriz. aspx Note / Product PA s can only be requested using this form* Approval does not ensure eligibility. Please verify Medicaid eligibility before completing this form* REQUESTOR RECIPIENT Must be requested by prescriber. See below. Requestor Name Print Last Name First Name Middle I. DOB Medicaid ID mm/dd/yyyy 10-digits PRESCRIBER Name Revised 1-2013 Phone Sex Male Female NPI Fax Specialty DEA Doses 3 units per day OR 24 mg per day will NOT be approved* Only 1 strength of 1 product will be authorized for use at a given time. Check one Box SL Tab 2mg sublingual film 2mg/0. 5mg SL Tab 2mg/0. 5mg Quantity Sig RATIONALE FOR PRIOR AUTHORIZATION Primary Diagnosis ICD-....

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Under Magellan's policies and procedures, the standard timely filing limit is 60 days. For exceptions to timely filing requirements for specific states and plans, sign in to this website to view our timely filing exceptions.

Where is Magellan Rx Management's headquarters? Magellan Rx Management's headquarters is located at 4801 E Washington St, Phoenix.

Magellan is headquartered in Phoenix, Arizona, the US.

About Magellan Health : Headquartered in Scottsdale, Ariz. , Magellan Health, Inc . is a healthcare management company that focuses on fast-growing, complex and high-cost areas of healthcare, with an emphasis on special population management.

Magellan manages some components of Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) HMO, POS, PPO, and Medicare provider networks for outpatient mental health and substance use disorders services.

Centene, a dominant company in Medicaid managed care, acquired Magellan Health in January for $2.2 billion but has been selling off chunks of the parent company since. In addition to selling Magellan Rx to Prime Therapeutics, St.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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