The antipsychotic prior authorization form is a required document in Maryland's Medicaid Pharmacy Program. It applies to patients aged 10 years and older who need Tier 2 or Non-Preferred antipsychotic medications. Health care providers must submit this form to request approval before these medications can be dispensed through Medicaid services.
Completing the form requires current prescriber information, including name, specialty, National Provider Identifier (NPI), and contact details. Providers must also document patient information: demographics, Medicaid ID, DSM-IV-TR diagnosis, target symptoms, and full medication history. Any prior treatment failures or drug-drug interactions with other antipsychotic medications must be reported to support the request.
For Non-Preferred medication requests, providers must state the clinical reasons why a preferred antipsychotic is not appropriate, or confirm the medication continues therapy begun in an inpatient setting. The prescriber's certification and signature confirm that treatment benefits outweigh the risks under current state Medicaid guidelines.
Incomplete submissions may delay or deny access to medications. Review each section before submitting. For related authorization forms, see the Aetna Pharmacy Prior Authorization Form, the Drug Prior Authorization Form, and the CCP Prior Authorization Request Form.
| 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 |