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 pr​escrib​ers 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 Service PA Form (Override Requests, Form DHMH3495C)

• Nutritional Supplement Provider Notification of Approval/Rejection of Requests (Form DHMH 3495B)
  

   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​
  
  

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