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 Information

Name	Description	Date
MEPARTD CO-PAY AND PLAN CHANGES EFFECTIVE 01/01/10 63 kB		2009/12/18
Plan Change 01.03.2008 27 kB		2008/01/04
S5617 Formulary PACriteria 2007 364 kB		2007/04/03
Prior-Authorization-Criteria-and-Guidelines-2007-4-Tier 650 kB		2007/04/03
Prior-Authorization-Criteria-and-Guidelines-2007-3-Tier 626 kB		2007/04/03
Maine CS Requirments 232 kB		2007/04/03

Medicare Part D Forms

Name	Description	Date
Part B/D Combo Claim Form 310 kB		2008/10/20

Fox Rx Care - PA Forms and Related Information

Name	Description	Date
Alzheimers 63 kB		2007/04/03
Amphetamine Products 54 kB		2007/04/03
Celebrex 125 kB		2007/04/03
Diflucan 51 kB		2007/04/03
Elidel 84 kB		2007/04/03
Expedited Formulary Exception Request Form 70 kB		2007/04/03
Expedited Redetermination Request Form 64 kB		2007/04/03
Formulary Exception Request Form 73 kB		2007/04/03
Forteo 53 kB		2007/04/03
Fuzeon 94 kB		2007/04/03
GrowthHormones 38 kB		2007/04/03
Hematopoietic Agent 129 kB		2007/04/03
Hepatitis B Vaccine 52 kB		2007/04/03
Humira 63 kB		2007/04/03
IntronA 44 kB		2007/04/03
Lotronex 52 kB		2007/04/03
Multiple Sclerosis 40 kB		2007/04/03
Miscellaneous 37 kB		2007/04/03
Provigil 36 kB		2007/04/03
Rebetol 131 kB		2007/04/03
Rebetron 132 kB		2007/04/03
Regranex 39 kB		2007/04/03
Retinoid 37 kB		2007/04/03
Roferon 38 kB		2007/04/03
Standard Redetermination Request Form 29 kB		2007/04/03
Strattera 39 kB		2007/04/03
Tier Exception Request Form 37 kB		2007/04/03
Zelnorm 37 kB		2007/04/03
Zofran 36 kB		2007/04/03

Cignature-Rx PA Forms and Related Information

Name	Description	Date
General PA Form 102 kB		2007/08/07

Wellcare - PA Forms and Related Information

Name	Description	Date
Redetermination 247 kB		2007/04/03
PDP Appeal Request 31 kB		2007/04/03
Medicare DER Form 74 kB		2007/04/03
Injectible 65 kB		2007/04/03
Model Coverage Determination Request Form 244 kB		2007/04/03

Rx Prescription Solutions - PA Forms and Related Information

Name	Description	Date
Medication Prior Authorization Request Form 23 kB		2007/04/03
AARP_CMS Model PartD Exception and Prior Authorization Form 31 kB		2007/04/03

Imedecs - PA Forms and Related Information

Name	Description	Date
Appeal Request Form 132 kB		2007/04/03

AARP - PA Forms and Related Information

Name	Description	Date
AARP Pharmacy NetworkFiles 90 kB		2007/08/07
AARP Formulary 6 MB		2007/08/07

Maximum - PA Forms and Related Information

Name	Description	Date
Reconsideration 254 kB		2007/04/03