DHMH October 2014
Request for Rx Prior Authorization
Do Not Use for Antipsychotic Requests
Maryland Medicaid
Pharmacy Program
Fax: (866) 440-9345
Phone: (800) 932-3918
Please check the appropriate box for the Prior Authorization request.
Quantity Limit Override Age Override Non-Preferred Clinical Criteria Other ____________
Please provide rationale for this request: ____________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
To find an alternative drug that is available without prior approval, see the Department's Preferred
Drug list at: https://mmcp.dhmh.maryland.gov/pap/SitePages/Preferred%20Drug%20List.aspx
Date __ __ - __ __ - __ __
Patient’s Information (required): Name: __________________________________________________
DOB: __________________ Recipient’s Maryland Medicaid Number: _____________________________
Prescriber’s Information (required): Name: _______________________________________________
NPI #: ___________________ Phone #: ____________________ Fax #: _______________________
Contact Person for this Request (required): Name: ________________________________________
Phone: __________________________________ Fax: __________________________________
Use a separate form for EACH medication request
Medication: _____________________________ Strength: ______ Quantity: ____ Refills: ____
New Prescription Refill (Patient has been taking this medication)
Note: If the generic is not acceptable, the prescriber must complete a DHMH MedWatch Form.
https://mmcp.dhmh.maryland.gov/pap/SitePages/[DHMH]%20Medwatch%20Form.aspx
Directions for Use: ______________________________________ Length of Treatment ________
1. Diagnosis/Indication: _____________________________________________________________
Prescriber’s Signature___________________________________ Date____________________
To encourage the safe and appropriate use of drugs while containing costs, clinical criteria have been
developed for some medications. To view clinical criteria, select this link:
https://mmcp.dhmh.maryland.gov/pap/SitePages/Clinical%20Criteria.aspx
Fax this completed form to 866-440-9345, once all the required information has been
provided. Incomplete forms will be returned.
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