Maryland Medicaid's Office of Pharmacy Services uses this one-page form for fee-for-service pharmacy prior authorization: age overrides, clinical criteria, non-preferred drugs, quantity limits and other edits. Prescribers meet it when a prescription for a fee-for-service member, or a carved-out mental health or substance use drug, needs prior authorization. Antipsychotics use their own forms, and incomplete forms are not reviewed.
The prescriber completes the patient, prescriber and prescription sections, gives the diagnosis and rationale, checks the two attestations and signs; a contact person can be listed for follow-up. The patient completes nothing.
Download the current version from the source each time; forms change without notice.
General Prior Authorization (PA) Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The form is marked Do Not Use for Antipsychotics. Maryland Medicaid has separate antipsychotic prior authorization forms for adults, for youth, and for long-acting injectables in members under 18, posted on the same Pharmacy Program Forms page.
Yes. The form states that MDH and the prescriber agree the request may be executed by electronic signature, which counts as an original signature for all purposes. The prescriber still checks the attestations about clinical trials and benefits outweighing risks before signing.
Generally no. It covers Maryland Medicaid fee-for-service pharmacy benefits and the carved-out mental health and substance use drugs. HealthChoice MCO members go through their own MCO's pharmacy prior authorization process and forms.