Antipsychotic Prior Authorization Form PDF Details

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.

QuestionAnswer
Form NameAntipsychotic Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshow to fill out medical prior authorization university of maryland, md antipsychotic form, maryland physician care prior auth form, maryland medicaid prior authorization form antipsychotic

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Maryland Medicaid Pharmacy Program ***Complete only for patients age 10 years and older*** Phone: 1-800-932-3918 and Fax: 1-866-440-9345

Tier 2 and Non-Preferred Antipsychotic Prior Authorization Form

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

Anti-social or Borderline Personality D/O

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

Self-injurious Behavior

 

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 drug-drug interaction between another medication and the preferred medication? Yes

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)

How to Edit Antipsychotic Prior Authorization Form Online for Free

Editing the antipsychotic prior authorization form on FormsPal is straightforward. Health care providers and prescribers can complete, fill out, and download the PDF in a few steps.

How to Fill Out the Antipsychotic Prior Authorization Form

  1. Enter prescriber information. Include your name, specialty, NPI number, and current contact details for the Medicaid request.
  2. Add patient information. Provide the patient name, date of birth, Medicaid ID, DSM-IV-TR diagnosis code, and target symptoms.
  3. Specify the antipsychotic medication. List the drug name, dosage, and frequency. Note whether this continues inpatient therapy.
  4. Document treatment history. Record any prior antipsychotic medications tried, treatment failures, and reasons a preferred drug is not appropriate.
  5. Sign and certify. The prescriber's signature certifies that the benefits outweigh the risks. Submit the completed form to Maryland Medicaid health services.

For other authorization forms, see the Superbill for Mental Health or the Ambetter Inpatient Prior Authorization Form.

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