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General PA Form
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)
High Cost Drugs
High Cost Drug PA Form
High Cost Drug Pharmacist Dispensing Record
High Cost Drug Standard Invoice and Billing Instructions
Medwatch Form *For prescribers to justify and attest for “Brand Medically Necessary"
Instructions for Completing Medwatch Form
Maryland Medwatch Form
Specialty PA Forms
Botox or Myobloc PA From (not for cosmetic use)
Prolia or Forteo PA Form
Growth Hormone PA Form
Ingrezza PA Form
Kuvan PA Form
Nicotine Replacement Therapy (NRT) PA Form
Opioid PA Form
Orfadin or Nityr PA Form
PDE-5 Inhibitors (for PAH) PA Form
Revlimid PA Form
Serostim PA Form (for treatment of AIDS Wasting Syndrome)
Spinraza PA Form
Spravato PA Form
Xgeva PA Form
Synagis PA Forms *Updated for 2021-2022 RSV Season
Synagis Memo to Providers
Synagis Service PA Form (Initial)
Synagis Service PA Form (Weight)
Synagis Pharmacy Billing Instructions
Nutritional Supplement PA Forms
Nutritional Supplement PA Form (Statement of Medical Necessity, Form DHMH3495)
Nutritional Supplement Provider Notification of Approval/Rejection of Requests (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 PA Form
Clotting Factor Replacement Therapy PA Forms
Clotting Factor Therapy PA Form (Initiation)
Clotting Factor Standard Invoice
Clotting Factor Pharmacist Dispensing Record
Clotting Factor Recipient-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