For Providers

Prescriber Protocols

Prior authorization process

Maricopa County Medicaid Pharmacy Program
Behavioral health medical practitioners may request prior authorization by fax (or by phone for urgent requests), using the following process:

1. Review the formulary and the prior authorization criteria.
2. Complete one of the prior authorization request forms below in the Prior Authorization Request Form section.
3. Fax the completed prior authorization request form to (866) 498-0628.
4. For urgent requests, call the Pharmacy Help Desk at (800) 790-1631.
5. You will be notified of the initial decision as quickly as possible and no later than 24 business hours.
6. If the request is not approved, the consumer will receive a notice of action on how to appeal the decision if needed.

Prior authorization criteria

• ADHD medications in children less than four years old
• Antipsychotics in children birth to five years old
• Clozapine and Fluvoxamine Combination
• Combination Stimulant Treatment
• Exceeding maximum daily recommended dose
• High Dose Anxiolytic Benzodiazepines
• Polypharmacy - Antipsychotics
• Monoamine Oxidase Inhibitors in Combination with other Antidepressants
• Risperdal Consta for Title XIX and Title XXI members (04-22-11)
• Risperdal Consta for non-title 19 members
• Tricyclic Antidepressant and Fluoxetine Combination
• Prior Authorization- Low Dose Seroquel® (Nov. 2011)
• Seroquel XR Prior Authorization Criteria New Starts (4-24-12)
• Ziprasidone Non-Titled SMI Prior Authorization Criteria (4-24-12)
• Olanzapine Prior Authorization on the Non-Title XIX SMI Formulary (11-21-11) 

• Prior Authorization-Combination SNRIs and Atomoxetine

Prior authorization request form

• General Prior Authorization Request Form (09-01-10)
• Atypical Bridge Prior Authorization Request Form (09-01-10)
• Risperdal Consta Prior Authorization Request Form (11-01-11)
• Fax Authorization Request form for Pharmacy Lock-In (09-30-11)
• Maricopa Prior Authorization Form Atypical Bridge (4-24-12)

Prescriber guidelines

• Prescribing guidelines for antidepressants (108K)
• Prescribing guidelines for atypical antipsychotics (123K)
• Prescribing guidelines for stimulants for ADHD (104K)
• Adjunctive Use Atypical Antipsychotics (4-19-12)

Clozapine process

• Clozapine program processes (17KB)

  Educational Materials Regarding QT Prolongation 

• FAQ Citalopram, Escitalopram and QTc prolongation for behavioral health medical practitioner's 
• Patient's Handout for Citalopram/Escitalopram and the FDA Warning

• Information on Valley Fever Treatment and Psychotropic Medications

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