Prior Authorization (PA) Forms

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 

• Instructions for Completing Medwatch Form
• Maryland Medwatch Form
  

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)
  

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, Nityr PA Form​
  
• Revlimid PA Form
  
• Spinraza PA Form
  
• Spravato PA Form​
  
• Wegovy or Zepbound PA Form​
  
• Xgeva PA Form 
  

Substance Use Disorder PA Forms

• Vivitrol PA Form​

• Sublocade and Brixadi PA Form​