General PA Forms

• ​PA Form (for Preferred Drug List medications other than antipsychotics) 

Antipsychotic PA Forms

• Antipsychotic Tier 2 and Non-Preferred for Adults (≥18 years) PA Form
• Antipsychotic PA Form for Youth ≤17 Years Old (For Peer Review Program, PRP)​
  
• Request to Authorize Long-Acting Injectable (LAI) Antipsychotic Prescription for Children Under Age 18 Form​
  

High Cost Drug Forms

• High Cost Drug PA Form​

Medwatch Form 

​For pr​escrib​ers to justify and attest for “Brand Medically Necessary"

• Instructions for Completing Medwatch Form
• Maryland Medwatch Form

Specialty PA Forms

• Fertility Preservation Medication PA Form
• Forteo + Prolia PA Form​​
• Gender Affirming Medication PA Form​
• Growth Hormone PA Form
• Imcivree PA Form​
• Ingrezza PA Form​
• Kuvan PA Form
• Nicotine Replacement Therapy (NRT) PA Form
• Opioid PA Form
• Orfadin or Nityr PA Form
• Revlimid PA Form
• Serostim PA Form (for treatment of AIDS Wasting Syndrome)
• Spinraza PA Form
• Spravato PA Form​
  
• Wegovy or Zepbound PA Form​
  
• Xgeva PA Form 

Synagis PA Forms 

Updated for 2024-2025 RSV Season

• Synagis Memo to Providers
• Synagis Prior Authorization (PA) Form
  
• Synagis Service Prior-Authorization form: For Pharmacy Use Only​
  
• Synagis Pharmacy Billing Instructions

 Nutritional Supplement PA Forms

• Nutritional Supplement PA Form (Statement of Medical Necessity, Form DHMH3495)
• Nutritional Supple​ment Provider Notification of Approval/Rejection of Reques​ts​ (Form DHMH 3495B)
• Nutritional Supplement Service PA ​Form (Form 3495C is no longer in use by OPS)

Substance Use Disorder PA Forms

• Vivitrol PA Form​
• Sublocade and Brixadi PA Form

Clotting Factor Replacement Therapy PA Forms

• Clotting Factor PA Form​
• Hemlibra PA Form​​​
• Clotting Factor Standard Invoice
• Clotting Factor Pharmacist Dispensing Record
• Clotting Factor Re​cipient-Kept Administration Record 

 Pharmacy Compounding

• Memo (04/12/2007) – ​New Billing Procedures for Home Intravenous Infusion Therapy
• Standard Invoice and Instructions for Completing Invoice for all IV Compounds
• Online Billing Instructions for Compounded Home Intravenous Therapy Claims​