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Prior Authorization for Antipsychotic Medications
For our updated (new) PA forms,
Please see the links below
 
For The Peer Review Program (Ages 0 to 17 years)
 
 
For Tier 2 and Non-Preferred Prior Authorizations (Ages 18 years and up) 
 
 

Information for Consumers

The Maryland Medicaid Pharmacy Program (MPP) Provides services for the following programs:

Medical Assistance

Receive complete pharmacy services.

HealthChoice

Receive Medicaid Mental Health Formulary and AIDS/HIV drugs - All other drugs are provided by HealthChoice Managed Care Organizations (MCOs).

Family Planning

Receive only contraceptives and sexually transmitted infections treatment.

Medicare Part D

Fully dual eligible Medicare beneficiaries receive most drugs excluded from Medicare Coverage -- All other drugs are provided by Medicare Prescription Drug Programs (PDPs). Please note that beginning 01/01/2013, drug coverage for Benzodiazepines and Barbiturates for those patients that are both Medicaid and Medicare eligible,will be provided by Medicare Part D Prescription Drug Plans  and not the Maryland Medicaid Pharmacy Program. This change may cause patient co-payments to vary.

Do eligibility requirements differ for various benefit groups?

Yes, however, all applicants must be U.S. citizens or qualified aliens.

Medicaid is available to low-income persons in certain categories.  Federal Medicaid laws require that every state cover certain groups.  For example, people who receive money through Supplemental Security (SSI) or Temporary Cash Assistance (TCA) automatically receive Medicaid.  In addition, persons may qualify for Medicaid because of high medical expenses (commonly hospital or nursing home care), if they have low income and assets and are aged, blind, or disabled.  Coverage is also allowed for certain optional categories.  For full eligibility requirements for the groups covered by Maryland's Medicaid Program, see Medical Care Programs Eligibility.

The HealthChoice program is Maryland's Medicaid's managed care program.  It is a mandatory program for most of the Medical Assistance population.  A recipient in HealthChoice will receive health care services through a managed care organization (MCO).  Approximately 80 percent of the Medicaid population participates in HealthChoice.

The Family Planning program provides medical services related to family planning for women who lost their Medicaid coverage after they were covered for a pregnancy and for women who meet the Program's eligibility criteria.  The covered services include medical office visits, physical examinations, contraceptives, related laboratory services, certain anti-infective medications, family planning supplies, reproductive education, counseling and referral, and tubal ligation. 

Medicare Part D provides complete pharmacy services to individuals who are eligible for both Medicare and Medicaid except certain drugs that are excluded from Medicare.  Medicaid provides most of those excluded drugs to dual eligible recipients. For contact information on each of the Medicare Part D Prescription Drug Plans .Click here

What is the cost for services?

The amount of the co-payment depends upon the program.  The following table shows the amounts for generic and preferred brand name drugs as well as other brand name drugs.

Fee for Service Co-Payments

Program

Generic and Preferred

Brand Name Drugs

Other Brand

Name Drugs

Medical Assistance (Fee-for-service recipients) $1.00 $3.00
HealthChoice (Most Mental Health Drugs and HIV/AIDS drugs Only) $1.00 $3.00
Family Planning (Contraceptives only) None None
Medicare Part D Dual Eligible Recipients (Medicare excluded drugs only) $1.00 $3.00

Note: For Medical Assistance and HealthChoice recipients, the copayment for both generic and brand name HIV/AIDS drugs is $1.00.

How do individuals apply for Medicaid?

People who receive Supplemental Security Income (SSI) or Temporary Cash Assistance (TCA) automatically qualify for Medicaid and do not need to apply.  Please see the Medicaid/Medical Assistance Overview page for enrollment information.

If you do not receive SSI or TCA, you must file an application to find out if you are eligible for Medicaid.  To do this, you must go to the Local Department of Social Services (LDSS) in the city or county where you live.  If you are applying for a child or are pregnant, you may file an application for the Maryland Children’s Health Program (MCHP), which covers the same services as Medicaid.  You may apply at your Local Health Department (LHD)  for MCHP or to be screened for breast or cervical cancer.  If you are elderly and are only applying for assistance with paying your Medicare premiums, co-payments, or deductions, you may apply at your local Area Agency on Aging (AAA).

The Maryland Medicaid Pharmacy Program Recipient Access Hotline

Recipients with pharmacy related issues may call the toll-free Medicaid Pharmacy Program Recipient Access Hotline at 1-800-492-5231.  Local Baltimore Metropolitan area callers may dial 410-767-5800.  Do not use these numbers for eligibility or enrollment issues.  Calls are accepted from 8:00 a.m. to 5:00 p.m. Monday through Friday.  Callers may leave a message before or after hours and on weekends and holidays.  Pharmacy staff will return calls on the next business day.