Pharmacy Forms
Attention Pharmacies: Emergency Supply Policy
In an emergency situation, dispensing of up to a 96-hour supply of covered outpatient drugs that require prior authorization (PA) will be allowed. An approved PA (if required) will be necessary to get additional medication. If the prescriber is not available and the pharmacist feels the recipient needs to receive the prescribed drug, the pharmacist should contact the Clinical Call Center at (855) 455-3311 or the Technical Call Center at (866) 244-8554. OptumRx, the pharmacy benefit manager, may authorize a 96-hour emergency supply.
NOTE: An emergency situation is a situation that, in the judgment of the dispensing pharmacist, involves an immediate threat of severe adverse consequences to the recipient, or the continuation of immediate and severe adverse consequences to the recipient, if an outpatient drug is not dispensed when a prescription is submitted.
The Emergency Supply Policy is specified in the Medicaid Services Manual (MSM) Chapter 1200 Prescribed Drugs and the Pharmacy Billing Manual.
Pharmacy PA Forms
Pharmacy forms are for completion and submission by current Medicaid providers only. Use the forms below to request prior authorization. Attach documentation to support the request as needed. If you have questions, call Nevada Medicaid at (800) 525-2395.
Other Pharmacy Forms
Pharmacy forms are for completion and submission by current Medicaid providers only.
| Form Number | Title |
|---|---|
| FA-60 | MAC Pricing Appeal Form |
| FA-62 | Request for Pharmaceutical Product Review |
Diabetic Supply Forms
| Form Number | Title |
|---|---|
| FA-200 | Continuous Glucose Monitors (CGMs) Prior Authorization Request Form |
| FA-201 | Insulin Pump Prior Authorization Request Form |
Nevada DHCFP Form
| Form Number | Title |
|---|---|
| NMO-4 | Request for Pharmacy Change for Lock-In Recipients |