Maryland Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Maryland Medicaid prior authorization form allows a Maryland physician to request Medicaid coverage for a prescription drug not on the Preferred Drug List. They must submit a completed form to the Maryland Medicaid Pharmacy Program. On this page, they can download a fillable PDF version of this form to complete on their computer. Once completed, fax the request to the fax number provided below. For more information or to make a prior authorization request over the phone, call the phone number found immediately below the fax number.

Fax – 1 (866) 440-9345

Phone – 1 (800) 932-3918

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

How to Write

Step 1Download the form and open it with either Adobe Acrobat or Microsoft Word.

Step 2 – Check one of the boxes to indicate whether this request is regarding a quantity limit override, age override, non-preferred prescription, or clinical criteria. If it is for another reason, select other and provide a reason. Then, in the field marked “Please provide the rationale for this request,” describe your justification(s) that necessitate the prescription of this drug.

Step 3 – Write the date.

Step 4 – In the “Patient’s Information” section, provide the patient’s name, date of birth, and Medicaid number.

Step 5 – Next, write your name, NIP number, phone number, and fax number into the indicated fields of the “Prescriber’s Information” section.

Step 6 – You are also required to provide the name, phone number, and fax number of a “Contact Person for this Request.”

Step 7 – Where it says “Medication,” write the name of the drug. Then enter the “Strength,” “Quantity,” number of “Refills,” and indicate whether this is a new prescription or a refill.

Step 8 – Next, write the “Directions for Use,” “Length of Treatment,” and the relevant “Diagnosis/Indication.”

Step 9 – Enter the date where indicated at the bottom of the page and print your completed form. Then, add your handwritten signature and fax your request to the Maryland Medicaid Pharmacy Program.