Get Md_preferred Drug Program - Maryland Pharmacy Programs

The MD_Preferred Drug Program is designed to facilitate the process of requesting prior authorization for specific medications in Maryland's pharmacy programs. This guide provides step-by-step instructions for filling out the request form online, ensuring a straightforward experience for users.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's Medicaid ID number in the provided field.
3. Fill in the patient’s date of birth accurately.
4. Complete the patient’s full name to identify the individual requiring the medication.
5. Enter the prescriber’s full name to associate the request with the medical professional.
6. Provide the prescriber’s street address, followed by the city, state, and zip code.
7. Fill in the prescriber’s phone number and fax number for communication purposes.
8. Enter the prescriber’s DEA number if applicable for the requested medication.
9. Indicate the person completing the form, if not the prescriber.
10. Specify the drug requested and check if the generic version is not acceptable.
11. Select the strength and dosage form of the drug requested.
12. Input the quantity of medication needed as prescribed.
13. Provide clear directions for use of the medication.
14. Answer the question regarding the diagnosis for the use of this medication.
15. Explain the reason for choosing a non-preferred or non-recommended Tier 1 drug by selecting all applicable options.
16. Date the form appropriately.
17. Obtain the prescriber’s signature to validate the request.
18. Fax the completed form to the Maryland Pharmacy Program at the fax number provided.

Begin filling out your MD_Preferred Drug Program form online today to ensure timely processing.