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It provides a standardized framework for healthcare providers to request coverage for medications that require clinical review, excluding antipsychotics. The form captures essential patient demographics, prescriber details, and specific prescription information including diagnosis and clinical rationale. It outlines the process for non-preferred drug requests, quantity limits, and clinical criteria, while providing direct links to the Preferred Drug List and clinical criteria guidelines. The form includes an attestation section where the prescriber certifies that the treatment benefits outweigh potential risks and that the provided clinical data is accurate. By facilitating electronic signatures, the document ensures a streamlined, legally recognized submission process for medical necessity, ultimately supporting the safe, appropriate, and cost-effective utilization of pharmacy benefits for Maryland Medicaid participants.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/general-prior-authorization-form-maryland-department-of-health/288879/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/general-prior-authorization-form-maryland-department-of-health/288879.png","ImageObject",442,249,{"name":88,"@type":89},"Ava Thompson","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of the General Prior Authorization form?","Question",{"text":109,"@type":110},"The form is used to request Medicaid coverage for medications that require prior approval, such as non-preferred drugs or those exceeding quantity limits.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Can this form be used for antipsychotic medications?",{"text":114,"@type":110},"No, this specific form explicitly states that it should not be used for antipsychotic medications.",{"name":116,"@type":107,"acceptedAnswer":117},"Where can I find the list of medications that do not require prior approval?",{"text":118,"@type":110},"You can access the Maryland Department of Health Preferred Drug List via the link provided in the document.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288879,1790110092,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},1649267921044,"https://us-avatar.wpscdn.com/avatar/1800007509477c92dfb?_k=1786009248482753345","General Prior Authorization (PA) Form Do Not Use for Antipsychotics  \nIncomplete forms will not be reviewed  \nMaryland Medicaid  \nOffice of Pharmacy Services  \nFax: (866) 440-9345  \nPhone: (833) 325-0105  \nDate:    \nThis prior authorization is for:  \n􀂉 Age override 􀂉 Clinical criteria 􀂉 Non-preferred drug 􀂉 Quantity limit 􀂉 Other:    \nTo find an alternative medication that is available without prior approval, please see the MDH Preferred Drug List at:  \n[https://bit.ly/4cOVHk5](https://bit.ly/4cOVHk5)  \nIf brand is required over its generic, please complete and submit the MedWatch Form: [https://bit.ly/4eQlaeO](https://bit.ly/4eQlaeO)  \nPatient Information  \nName:   DOB:   􀂉 M 􀂉 F  \nMedicaid Assistance Number:   Height:   Weight:    \nPrescriber Information  \nName:   NPI:    \nContact Person: Name:   Phone:   Fax:    \nPrescription Information  \n􀂉 Initial PA Request 􀂉 Renewal PA Request  \nMedication:   Strength:   Quantity:   Refills:   Directions for use:   Diagnosis:   Rationale of this request:    \nTo encourage the safe and appropriate use of medications while containing costs, clinical criteria have been developed for some medications. To view clinical criteria, select this link:  \n[https://health.maryland.gov/mmcp/pap/pages/Clinical-Criteria.aspx](https://health.maryland.gov/mmcp/pap/pages/Clinical-Criteria.aspx)  \nI attest that  \n􀂉 The requested medication is not part of a clinical trial.  \n􀂉 The benefits of the treatment outweigh the risks, and the information provided on this form is true and accurate to the best of my knowledge.  \nMDH and prescriber acknowledge and agree that this request may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.  \nPrescriber’s Signature  Date   \nMDH – November 2024","cbCaibR0Ys8WjvpG","https://ap.wps.com/l/cbCaibR0Ys8WjvpG","pdf",92761,"English","# Patient and Prescriber Information\n## Prescription Details and Rationale\n# Clinical Criteria and Resources\n## Attestation and Signature","[{\"question\":\"What is the purpose of the General Prior Authorization form?\",\"answer\":\"The form is used to request Medicaid coverage for medications that require prior approval, such as non-preferred drugs or those exceeding quantity limits.\"},{\"question\":\"Can this form be used for antipsychotic medications?\",\"answer\":\"No, this specific form explicitly states that it should not be used for antipsychotic medications.\"},{\"question\":\"Where can I find the list of medications that do not require prior approval?\",\"answer\":\"You can access the Maryland Department of Health Preferred Drug List via the link provided in the document.\"}]","General Prior Authorization Form - Maryland Department of Health | PDF",1789634143]