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Maryland Medicaid Prior (Rx) Authorization Form

Maryland Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

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