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Pharmacy
User: Visitor July 3, 2009
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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

PA - Prior Authorization Forms Archive

(click column headers to sort)
Name Description Date
Acute Migraine (copy) Acute Migraine (copy) 107 kB #10110  2006/01/12
MIscellaneous Non Preferred MIscellaneous Non Preferred 28 kB   2005/10/05
Antifungals (copy) Antifungals (copy) 118 kB #10120  2007/09/07
Botox Botox 42 kB   2005/10/05
Zofran Zofran 32 kB   2005/10/05
Brand Drugs (copy) Brand Drugs (copy) 109 kB #10220  2006/01/13
Cox II Inhibitors (copy) Cox II Inhibitors (copy) 31 kB #10310  2006/01/12
Dosage Strength Dosage Strength 26 kB   2005/10/05
EPO EPO 36 kB   2005/10/05
Raptiva Amevive Raptiva Amevive 28 kB   2005/10/05
Provigil Provigil 31 kB   2005/10/05
Erectile Dysfunction Erectile Dysfunction 40 kB #10530  2005/10/05
Flumist (copy) Flumist (copy) 39 kB #10610  2006/01/12
Fuzeon Fuzeon 30 kB   2005/10/05
Growth Hormone (copy) Growth Hormone (copy) 40 kB #10710  2007/04/13
Growth Hormone Growth Hormone 30 kB   2005/10/05
Flumist Flumist 36 kB   2005/10/05
Erectile Dysfunction Erectile Dysfunction 38 kB   2005/10/05
Miscellaneous Non Preferred (copy) Miscellaneous Non Preferred (copy) 32 kB #20420  2006/01/12
Enbrel Remicade Enbrel Remicade 29 kB   2005/10/05
MS Agents MS Agents 42 kB   2005/10/05
Cox II Inhibitors Cox II Inhibitors 34 kB   2005/07/01
Brand PA Brand PA 52 kB   2005/10/05
Multi Antipsychotic - Clinical PA (copy) Multi Antipsychotic - Clinical PA (copy) 32 kB #20440  2006/11/22
Antifungals Antifungals 38 kB   2005/10/05
Acute Migraine Acute Migraine 106 kB   2005/10/05
Zofran Zofran 34 kB #30810  2005/10/05
Enbrel Remicade Enbrel Remicade 32 kB #10510  2005/10/05
Narcotics (copy) Narcotics (copy) 35 kB #20510  2005/11/17
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 31 kB #30110  2005/11/17
Narcotics (copy) Narcotics (copy) 81 kB #20510  2007/10/25
Neupogen Leukine Neupogen Leukine 34 kB   2005/10/05
Non Sedating Antihistamines Non Sedating Antihistamines 31 kB   2005/10/05
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 60 kB #30110  2006/01/12
Narcotics (copy) Narcotics (copy) 76 kB #20510  2006/01/12
Phosphate Binders Phosphate Binders 27 kB   2005/10/05
Provigil (copy) Provigil (copy) 31 kB #20710  2006/11/22
Brand Drugs (copy) Brand Drugs (copy) 57 kB #10220  2006/01/12
Raptiva Amevive (copy) Raptiva Amevive (copy) 30 kB #20910  2007/01/29
Remicade/Kineret (copy) Remicade/Kineret (copy) 65 kB #10510  2007/06/26
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 62 kB #30110  2007/06/12
Synagis Respigam (copy) Synagis Respigam (copy) 37 kB #30120  2006/11/22
Sensipar Sensipar 29 kB   2005/10/05
Provigil (copy) Provigil (copy) 33 kB #20710  2005/12/05
Multi Antipsychotic - Clinical PA (copy) Multi Antipsychotic - Clinical PA (copy) 32 kB #20440  2006/11/22
Growth Hormone (copy) Growth Hormone (copy) 33 kB #10710  2006/11/22
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 29 kB #30110  2007/01/29
Subjective Global Assessment (SGA) Subjective Global Assessment (SGA) 28 kB   2005/10/05
Enbrel/Remicade (copy) Enbrel/Remicade (copy) 33 kB #10510  2007/01/29
Antifungals (copy) Antifungals (copy) 39 kB #10120  2007/01/29
Synagis Respigam Synagis Respigam 34 kB   2005/10/05
Synagis Respigam (copy) Synagis Respigam (copy) 37 kB #30120  2007/10/12
Narcotics (copy) Narcotics (copy) 37 kB #20510  2007/06/12
Transition Policy Transition Policy 431 B   2007/03/14
PDP Grandfathering Strategy PDP Grandfathering Strategy 459 B   2007/03/14
PDL Dosage Consolidation List_01.29.07 PDL Dosage Consolidation List_01.29.07 112 kB   2007/01/29
PA Analysis 2007 Standard vs Managed PA Analysis 2007 Standard vs Managed 522 B   2007/03/14
Growth Hormone (copy) Growth Hormone (copy) 82 kB #10710  2007/05/01
DUR Board Member List - 03/11/2004 DUR Board Member List - 03/11/2004 34 kB   2005/02/28
Customer Service Requirements Customer Service Requirements 566 B   2007/03/14
Customer Service Requirements Customer Service Requirements 226 kB   2007/03/14
Coverage Determination Review Process Coverage Determination Review Process 499 B   2007/03/14
Antifungals (copy) Antifungals (copy) 77 kB #10120  2007/04/13
Synvisc Synvisc 34 kB   2005/10/05
Syringe Filling Syringe Filling 26 kB   2005/10/05
Vivitrol (copy) Vivitrol (copy) 33 kB   2006/11/22
Zofran Zofran 34 kB #30810  2005/11/04
Zyvox Zyvox 28 kB   2005/10/05
Symlin (copy) Symlin (copy) 39 kB #301501  2007/11/06
Sensipar (copy) Sensipar (copy) 32 kB #30115  2007/11/06
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 96 kB #30110  2007/11/06
Remicade/Kineret (copy) Remicade/Kineret (copy) 98 kB #10510  2007/11/06
Raptiva Amevive (copy) Raptiva Amevive (copy) 34 kB #20910  2007/11/06
Provigil (copy) Provigil (copy) 33 kB #20710  2007/11/06
Phosphate Binders (copy) Phosphate Binders (copy) 28 kB #20720  2007/11/06
Non Sedating Antihistamines (copy) Non Sedating Antihistamines (copy) 32 kB #20530  2007/11/06
Multi Antipsychotic - Clinical PA (copy) Multi Antipsychotic - Clinical PA (copy) 34 kB #20440  2007/11/06
MS Agents (copy) MS Agents (copy) 45 kB #20430  2007/11/06
Miscellaneous Non Preferred (copy) Miscellaneous Non Preferred (copy) 29 kB #20420  2007/11/06
Growth Hormone (copy) Growth Hormone (copy) 82 kB #10710  2007/11/06
Four (4) Brand PA Form (copy) Four (4) Brand PA Form (copy) 36 kB #10600  2007/11/06
EPO (copy) EPO (copy) 36 kB #10520  2007/11/06
Dose Consolidation (copy) Dose Consolidation (copy) 33 kB #10420   2007/11/06
Cox II Inhibitors (copy) Cox II Inhibitors (copy) 30 kB #10310  2007/11/06
Brand Drugs (copy) Brand Drugs (copy) 53 kB #10220  2007/11/06
Acute Migraine (copy) Acute Migraine (copy) 161 kB #10110  2007/11/06
Synagis Respigam (copy) Synagis Respigam (copy) 74 kB #30120  2007/11/15
Zyvox (copy) Zyvox (copy) 33 kB #30820  2008/01/02
Oral Anabolic Steroid (copy) Oral Anabolic Steroid (copy) 31 kB #20600  2008/01/17
Growth Hormone (copy) Growth Hormone (copy) 123 kB #10710  2008/01/17
Byetta (copy) Byetta (copy) 33 kB #10230  2008/01/02
Antifungals (copy) Antifungals (copy) 159 kB #10120  2008/01/17
Maine Pharmacies Maine Pharmacies 83 kB   2006/08/29
MaineCare MAC List Effective 01.25.2007 MaineCare MAC List Effective 01.25.2007 160 kB   2007/01/15
Draft PDL for October DUR Meeting Draft PDL for October DUR Meeting 4 MB   2006/10/06
Synvisc (copy) Synvisc (copy) 37 kB #30130  2008/02/27
Botox - Myobloc (copy) Botox - Myobloc (copy) 42 kB #10210  2008/02/27
MS Agents (copy) MS Agents (copy) 91 kB #20430  2008/04/17
Acute Migraine Acute Migraine 109 kB #10110  2008/09/23
Narcotics Narcotics 38 kB #20510  2008/09/23
Zyvox (copy) Zyvox (copy) 100 kB #30820  2008/09/29
Vivitrol (copy) Vivitrol (copy) 65 kB #3400  2008/09/29
Syringe Filling (copy) Syringe Filling (copy) 29 kB #30140  2008/09/29
Synvisc (copy) Synvisc (copy) 74 kB #30130  2008/09/29
Synagis Respigam (copy) Synagis Respigam (copy) 113 kB #30120  2008/09/29
Symlin (copy) Symlin (copy) 78 kB #301501  2008/09/29
Subjective Global Assessment (SGA) (copy) Subjective Global Assessment (SGA) (copy) 27 kB   2008/09/29
Sensipar (copy) Sensipar (copy) 65 kB #30115  2008/09/29
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 129 kB #30110  2008/09/29
Rheumatoid/Crohns (copy) Rheumatoid/Crohns (copy) 34 kB #20900  2008/09/29
Provigil (copy) Provigil (copy) 68 kB #20710  2008/09/29
Oral Anabolic Steroid (copy) Oral Anabolic Steroid (copy) 63 kB #20600  2008/09/29
Ondansetron (copy) Ondansetron (copy) 37 kB #20610  2008/09/29
Non Sedating Antihistamines (copy) Non Sedating Antihistamines (copy) 63 kB #20530  2008/09/29
Neupogen Leukine (copy) Neupogen Leukine (copy) 34 kB #20520  2008/09/29
Narcotics (copy) Narcotics (copy) 160 kB #20510  2008/09/29
Multi Antipsychotic - Clinical PA (copy) Multi Antipsychotic - Clinical PA (copy) 67 kB #20440  2008/09/29
MS Agents (copy) MS Agents (copy) 141 kB #20430  2008/09/29
Miscellaneous Non Preferred (copy) Miscellaneous Non Preferred (copy) 62 kB #20420  2008/09/29
MaineCare MAC List Effective 10.25.2007 (copy) MaineCare MAC List Effective 10.25.2007 (copy) 221 kB   2008/09/26
Growth Hormone (copy) Growth Hormone (copy) 119 kB #10710  2008/09/29
Fuzeon (copy) Fuzeon (copy) 32 kB #10620  2008/09/29
Four (4) Brand PA Form (copy) Four (4) Brand PA Form (copy) 68 kB #10600  2008/09/29
Flumist (copy) Flumist (copy) 39 kB #10610  2008/09/29
EPO (copy) EPO (copy) 72 kB #10520  2008/09/29
Drug Drug Interactions (copy) Drug Drug Interactions (copy) 31 kB #10400  2008/09/29
Dose Consolidation (copy) Dose Consolidation (copy) 66 kB #10420   2008/09/29
Dosage Strength (copy) Dosage Strength (copy) 29 kB #10410  2008/09/29
Cox II Inhibitors (copy) Cox II Inhibitors (copy) 62 kB #10310  2008/09/29
Byetta (copy) Byetta (copy) 68 kB #10230  2008/09/29
Brand Drugs (copy) Brand Drugs (copy) 109 kB #10220  2008/09/29
Botox - Myobloc (copy) Botox - Myobloc (copy) 87 kB #10210  2008/09/29
Antifungals (copy) Antifungals (copy) 198 kB #10120  2008/09/29
Amevive (copy) Amevive (copy) 65 kB #20910  2008/09/29
Acute Migraine (copy) Acute Migraine (copy) 319 kB #10110  2008/09/29
Synagis Respigam Synagis Respigam 38 kB   2008/10/24
Synagis Respigam (copy) Synagis Respigam (copy) 39 kB #30120  2008/12/12
Narcotics (copy) Narcotics (copy) 202 kB #20510  2008/12/18
Sedative Hypnotics (copy) Sedative Hypnotics (copy) 163 kB #30110  2009/01/06
Growth Hormone (copy) Growth Hormone (copy) 161 kB #10710  2009/01/06
Acute Migraine (copy) Acute Migraine (copy) 368 kB #10110  2009/01/06
Non Sedating Antihistamines (copy) Non Sedating Antihistamines (copy) 97 kB #20530  2009/05/08
Med Watch Form (copy) Med Watch Form (copy) 268 kB   2009/05/08