Preferred Drug List Forms

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

Prior Authorization Request form for Tier 2  Non- Preferred  Prior Tier2 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 Medwatch Form. (For prescribers to use for attesting to justifications for "Brand Medically Necessary")

Instructions for Completing Medwatch form


Peer Review Program

Request to Authorize Antipsychotic Prescription PA form (Children 0- 17 years)

Speciality Forms

Kuvan PA Form

Botox or Myobloc Prior Authorization (not for cosmetic use)

FORTEO PA FORM

Growth Hormone (GH) Pre-Authorization Request Form (For prescribers Statement of Medical Necessity for growth hormones)

Nicotine Replacement Therapy Fax

Nutritional Supplement Clinical PA Request  (or Statement of Medical Necessity, Form DHMH3495)

Provider Notification of Approval/Rejection of Nutritional Supplement Requests (Form DHMH3495B)

Nutritional Supplement Service PA or On-Line Override Requests (Form DHMH3495C)

Opioid PA form

Orfadin P

A form

PAH Drug Pre-authorization

Form

Revlimid Form (Pre-Authorization Form (For prescribers to certify that patient is not part of a clinical study of

s drug)

Serostim Form Treatment of AIDS Wasting Syndrome (For prescribers Statement of Medical Necessity for m treatment)

Synagis Memo to Providers
Synagis Billing Instructions
Synagis Service PA Form (Refill)
 

XGEVA PA FORM

Substance Use Disorder Forms
VIVITROL OR CAMPRAL 

 

Pharmacy Compounding

  • April 12, 2007 Memo New Billing Procedures for Home Intravenous Infusion Therapy (HIT)
  • Standard Invoice and Instructions for Completing Invoice for all IV Compounds
  • Online Billing Instructions for Compounded Home Intravenous Therapy (HIT) Claims

Clotting Factor 

  • Clotting Factor Standard Invoice
  • Clotting Factor Dispensing Record
  • Recipient-Kept Factor Infusing Log
  • High-Cost Drugs
  • High Cost Drug Preauthorization
  • High Cost Drug Pharmacist Dispensing Record
  • High Cost Drug Standard Invoice and Billing Instructions