201 W. Preston St.
Baltimore, MD 21201
Phone: 800-492-5231 Option: 3
Business Hours: Monday-Friday 8:30am–4:30pm EST

• Preferred Drug List

• Coordinated ProDUR

• COVID-19 Specimen Collection Payer Sheet
• COVID-19 Vaccine, Home Test Kits, and Oral Antiviral Payer Sheet
• D.0 Payer Sheet
• D.0 Payer Sheet (Reversal Only)

• Provider Manual
• Provider Cheat Sheet
• Provider Training Presentation
• MCO Procedures - Non-formulary Emergency Supply Policies
• PDL Clinical Criteria
• HealthChoice PBMs

Preferred Drug List Forms

• PDL Prior Authorization Request Fax Form
  (For prescribers to use for faxing preauthorization requests)
• PDL Medication Change Fax Form
  

For Submission to Conduent:

• Fentanyl Buccal Pre-Authorization Form
  (For prescriber's statement of criteria for Fentanyl Buccal)
• Maximum Quantity Override Request
  (For prescribers to request authorization to override maximum allowable quantities for any drug)
• Growth Hormone (GH) Pre-Authorization Request Form
  (For prescribers Statement of medical necessity for growth hormones)
• DHMH Medwatch Form
  (For prescribers to use for attesting to justifications for "Brand Medically Necessary")
  Instructions for Completing Medwatch Form
• Nutritional Prior-Authorization Request (Form 3495)
  
• Nicotine Replacement Therapy Fax Form
  
• Prolia/Forteo Fax Form
  
• Xgeva Fax Form
  
• Spravato Prior Authorization Form
  
• Synagis® (palivizumab) Memo 2021- 2022 RSV Season Clinical and Service Prior-Authorizations
  
• Synagis® (palivizumab) Prescriber's Statement of Medical Necessity
  
• Synagis® (palivizumab) Pre-Authorization Form
  (For prescriber's statement of medical necessity for Synagis - palivizumab)

For Submission to DHMH:

• Kuvan® Pre-Authorization Request Form
  
• Serostim® Treatment of AIDS Wasting Syndrome
  (For prescribers statement of medical necessity for Serostim treatment)
• Revlimid™ Pre-Authorization Form
  
• Botox or Myobioc Prior Authorization (not for cosmetic use)
  
• Orfadin® Pre-Authorization Request
  
• PAH Drug Pre-Authorization Form
  

Peer Review Program (Submission to UMB):

• Request to Authorize Antipsychotic Prescription
  (For children under 18 years of age)

Pharmacy Compounding

• Standard Invoice and Instructions for Completing Invoice for all IV Compounds
  
• On-line Billing Instructions for Compounded Home Intravenous Therapy (HIT) Claims
  (Table for computing TPN Costs)

Clotting Factor and High-Cost Drugs

• Clotting Factor Standard Invoice
  (Required for reimbursement of clotting factor)
• Clotting Factor Dispensing Record
  
• Recipient-Kept Factor Infusion Log
  
• High Cost Drug Preauthorization
  (See FY2010 DHMH Pharmacy Transmittal No. 192 for background)
• High Cost Drug Pharmacist Dispensing Record
  
• High Cost Drug Standard Invoice and Billing Instructions
  

• MAC and IDC Table

• Specialty Mental Health Formulary

Advisories

• Provider Advisories

• Provider Newsletters

• Transmittals from Maryland Department of Health and Mental Hygiene

• Emergency Fills

• Visit DHMH