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Pharmacy
User: Visitor July 25, 2008
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Provider Help Desk: (p) 888-420-9711 (f) 800-408-1088 | Member Help Desk: (p) 866-796-2463 (f) 207-287-8601
Prior Authorization (PA) Helpdesk (for Provider PA inquiries): (p) 888-445-0497 (f) 888-879-6938

Medicare Part D

Disclaimer

These publications are made available on the Office of MaineCare's website as a public service.  Although the Office of MaineCare Services makes an effort to provide accurate information, portions of text available may be incorrect or not current.  Its accuracy is not certified by the Office of MaineCare Services, Maine Department of Health and Human Services or the State of Maine.  The State, its agencies, officers and employees do not make any statutory, express or implied representation or warranty about the accuracy, reliability, completeness or timeliness of any information available and disclaim any liability for any losses resulting from any person's reliance on such information.  Any person relying on information contained within the text does so at the person's own risk.

 

Medicare Part D Forms

Part B/D Combo Claim Form Part B/D Combo Claim Form 1/4/2008 220 kB

Fox Rx Care - PA Forms and Related Information

Alzheimers Alzheimers 4/3/2007 63 kB
Amphetamine Products Amphetamine Products 4/3/2007 54 kB
Celebrex Celebrex 4/3/2007 125 kB
Diflucan Diflucan 4/3/2007 51 kB
Elidel Elidel 4/3/2007 84 kB
Expedited Formulary Exception Request Form Expedited Formulary Exception Request Form 4/3/2007 70 kB
Expedited Redetermination Request Form Expedited Redetermination Request Form 4/3/2007 64 kB
Formulary Exception Request Form Formulary Exception Request Form 4/3/2007 73 kB
Forteo Forteo 4/3/2007 53 kB
Fuzeon Fuzeon 4/3/2007 94 kB
GrowthHormones GrowthHormones 4/3/2007 38 kB
Hematopoietic Agent Hematopoietic Agent 4/3/2007 129 kB
Hepatitis B Vaccine Hepatitis B Vaccine 4/3/2007 52 kB
Humira Humira 4/3/2007 63 kB
IntronA IntronA 4/3/2007 44 kB
Lotronex Lotronex 4/3/2007 52 kB
Multiple Sclerosis Multiple Sclerosis 4/3/2007 40 kB
Miscellaneous Miscellaneous 4/3/2007 37 kB
Provigil Provigil 4/3/2007 36 kB
Rebetol Rebetol 4/3/2007 131 kB
Rebetron Rebetron 4/3/2007 132 kB
Regranex Regranex 4/3/2007 39 kB
Retinoid Retinoid 4/3/2007 37 kB
Roferon Roferon 4/3/2007 38 kB
Standard Redetermination Request Form Standard Redetermination Request Form 4/3/2007 29 kB
Strattera Strattera 4/3/2007 39 kB
Tier Exception Request Form Tier Exception Request Form 4/3/2007 37 kB
Zelnorm Zelnorm 4/3/2007 37 kB
Zofran Zofran 4/3/2007 36 kB

Cignature-Rx PA Forms and Related Information

General PA Form General PA Form 8/7/2007 102 kB

Wellcare - PA Forms and Related Information

Redetermination Redetermination 4/3/2007 247 kB
PDP Appeal Request PDP Appeal Request 4/3/2007 31 kB
Medicare DER Form Medicare DER Form 4/3/2007 74 kB
Injectible Injectible 4/3/2007 65 kB
Model Coverage Determination Request Form Model Coverage Determination Request Form 4/3/2007 244 kB

Rx Prescription Solutions - PA Forms and Related Information

Medication Prior Authorization Request Form Medication Prior Authorization Request Form 4/3/2007 23 kB
AARP_CMS Model PartD Exception and Prior Authorization Form AARP_CMS Model PartD Exception and Prior Authorization Form 4/3/2007 31 kB

Imedecs - PA Forms and Related Information

Appeal Request Form Appeal Request Form 4/3/2007 132 kB

AARP - PA Forms and Related Information

AARP Pharmacy NetworkFiles AARP Pharmacy NetworkFiles 8/7/2007 90 kB
AARP Formulary AARP Formulary 8/7/2007 6 MB

Maximum - PA Forms and Related Information

Reconsideration Reconsideration 4/3/2007 254 kB