Preferred Drug List Forms

PDL Prior PA  Authorization Request Fax form   ( for prescribers to use for faxing preauthorization requests for Drugs other than antipsychotics)    

  Tier 2 and Non-Preferred PA FORM  Prior Authorization Request form  for Tier  2 Non Preferred Form for Patients 18 years and Older     (Children 0-17, use the Peer Review Program's Prior Authorization Request Form) 

PDL Medication Change Fax Form   (For pharmacists to use to notify prescribers of preferred alternatives and preauthorization requirements)

Quantity Limit

Maximum Quantity Override Request Form. (For prescribers to request authorization to override maximum allowable quantities for any drug)

Med Watch 

Maryland h Form. (For prescribers to use for attesting to justifications for "Brand Medically Necessary")

 

Peer Review Program

 

Speciality Forms

 

Substance Use Disorder Forms

 

Pharmacy Compounding

 

Clotting Factor 

 

High-Cost Drugs