There is a new antipsychotic prior authorization form that pharmacies and prescribers will need to use for all outpatient prescriptions of antipsychotics. The form went into effect on January 1, 2017, and is required for all Medicaid members. This form will help ensure that patients are receiving the most appropriate medication for their condition. Prescriptions written before January 1, 2017, do not need to be resubmitted using the new form. For more information on the new antipsychotic prior authorization form, please visit our website or contact us by phone or email. Thank you for your continued support of our pharmacy!
| Question | Answer |
|---|---|
| Form Name | Antipsychotic Prior Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | how to fill out medical prior authorization university of maryland, md antipsychotic form, maryland physician care prior auth form, maryland medicaid prior authorization form antipsychotic |
Maryland Medicaid Pharmacy Program ***Complete only for patients age 10 years and older*** Phone:
Tier 2 and
Prescriber Information
Prescriber Name: _______________________________________NPI #: _______________Specialty: ___________
Mailing Address: _______________________________________________________________________________
Tel: ________________ Fax: _______________ Email: ________________________________________________
Patient Information
Patient Name: _____________________________________________ Patient MA#: _________________________
Mailing Address: _______________________________________________________________________________
DOB (MM/DD/YY): _________________ Male ___ Female ___ Height (inches): _______ Weight (pounds): _______
DSM - IV - TR Diagnosis (check all that apply)
ADHD
Asperger’s Disorder or PDDNOS Autistic Disorder
Bipolar Disorder
Conduct or Oppositional Defiant D/O Dementia
Generalized Anxiety Disorder Major Depressive Disorder Mental Retardation Obsessive Compulsive D/O Panic Disorder
Psychotic D/O Not Schizophrenia (specify):____________________
PTSD
Schizoaffective D/O
Schizophrenia
Social Phobia
Tourette’s Disorder
Other (specify):
____________________
Target Symptoms (check all target symptoms for which drug is being prescribed)
Aggression
Assault
Delusion
Depression
Hallucinations |
Mania |
Insomnia |
Mood lability |
Irritability |
|
|
Other:_________________ |
Antipsychotic for which authorization is being sought: (check)
Abilify®
Fanapt®
Fazaclo®
Invega®
Invega Sustenna® Latuda® olanzapine olanzapine/fluoxetine
Saphris® Seroquel XR® Zyprexa Relprevv® other: _________
Dosage Form: ________________Strength: ______________ Frequency: __________________Quantity: __________
Dosage Form: ________________ Strength: _________ ______Frequency: __________________Quantity: __________
Is requested medication a continuation of therapy from an inpatient setting? |
Yes |
No |
Does the patient have a condition that prevents the use of the preferred medication? |
Yes |
|
No
If yes, please specify: ________________________________________________________________
Is there a
If yes, please specify: ________________________________________________________________
Has the patient experienced treatment failure with other medications? Yes No
No
If yes, please list which medications the patient has tried:
Medication Name
Strength/Frequency
Duration of Treatment
Compliance
(at least 6 days/wk)
Reason for Discontinuation
I certify that the benefits of antipsychotic treatment for this patient outweigh the risks.
Prescriber Signature: ___________________________________________ Date: _________________________
(DHMH Sept. 2012)