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Maryland Medicaid Prior (Rx) Authorization Form

Maryland Medicaid prior authorization form allows a Maryland physician to request Medicaid coverage for a prescription drug that is not on the preferred drug list. The physician must submit the completed form to the Maryland Medicaid Pharmacy Program and provide the medical justification for prescribing a non-preferred drug.
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Downloads: 475

Fax – 1 (866) 440-9345

Phone – 1 (800) 932-3918

Preferred Drug List – List of pre-approved drugs by the State