Get Md Tier 2 And Non-preferred Antipsychotic Prior Authorization Form 2012-2025

Navigating the MD Tier 2 and Non-Preferred Antipsychotic Prior Authorization Form can seem daunting, but this guide will simplify the process for you. We aim to provide clear and supportive instructions to help you fill out this important document efficiently and accurately.

Follow the steps to complete the authorization form effectively.

1. Press the ‘Get Form’ button to access the authorization form and open it in your preferred online editor.
2. Begin by filling out the prescriber information section. Include the prescriber's full name, NPI number, specialty, mailing address, telephone number, fax number, and email address.
3. Next, complete the patient information section. Provide the patient’s full name, Maryland Medicaid number, mailing address, date of birth, gender, height, and weight.
4. In the DSM-IV-TR diagnosis section, check all applicable diagnoses that the patient has been assigned.
5. Indicate the target symptoms for which the medication is being prescribed by checking all relevant symptoms listed.
6. Select the antipsychotic medication for which you are seeking authorization. Check the box next to the relevant medication options provided.
7. Fill in the dosage form, strength, frequency, and quantity for the requested medication in the provided fields.
8. Answer the following questions regarding the medication: whether it is a continuation from an inpatient setting, if there is a condition preventing the use of preferred medication, potential drug-drug interactions, and past treatment failures with other medications.
9. For past treatment failures, specify the medications tried, their strength/frequency, duration of treatment, compliance, and reason for discontinuation.
10. Finally, the prescriber must certify that the benefits of the antipsychotic treatment for the patient outweigh the risks by signing and dating the form.
11. Once you have completed all sections of the form, ensure that all information is accurate. You can then save your changes, download the completed form, print it, or share it as needed.

Take the next step in your documentation process by filling out the MD Tier 2 and Non-Preferred Antipsychotic Prior Authorization Form online today.