PA - Prior Authorization Forms

Listed below are all the PA forms you will need in order to request drugs that require prior authorization.

MaineCare Preferred Drug List

To submit a request:

1. Select and print the proper form from the list below
2. Fill out the form completely
3. Fax the completed form to us at 1-888-879-6938

(Please note - If the PA form asks for supporting medical documentation, please fax this information along with the completed PA form.)

The forms are provided here in MS Word. If you cannot view a file, please download the appropriate free plug-in from the links below.

• MS Word Viewer (.doc or .rtf)
• MS Excel Viewer (.xls)
• Acrobat Viewer (.pdf)

Name	Description	Date
Acute Migraine 418 kB	#10110	2009/01/06
Amevive 99 kB	#20910	2008/09/29
Antifungals 239 kB	#10120	2008/09/29
Botox - Myobloc 135 kB	#10210	2008/09/29
Brand Drugs 164 kB	#10220	2008/09/29
Byetta 107 kB	#10230	2008/09/29
Cox II Inhibitors 97 kB	#10310	2008/09/29
Dosage Strength 60 kB	#10410	2008/09/29
Dose Consolidation 101 kB	#10420	2008/09/29
Drug Drug Interactions 63 kB	#10400	2008/09/29
EPO 110 kB	#10520	2008/09/29
Flumist 80 kB	#10610	2008/09/29
Four (4) Brand PA Form 103 kB	#10600	2008/09/29
Fuzeon 67 kB	#10620	2008/09/29
Growth Hormone 203 kB	#10710	2009/01/06
Med Watch Form 269 kB		2009/05/08
Miscellaneous Non Preferred 96 kB	#20420	2008/09/29
MS Agents 188 kB	#20430	2008/09/29
Multi Antipsychotic - Clinical PA 102 kB	#20440	2008/09/29
Narcotics 244 kB	#20510	2008/12/18
Neupogen Leukine 69 kB	#20520	2008/09/29
Non Sedating Antihistamines 132 kB	#20530	2009/05/08
Ondansetron 74 kB	#20610	2008/09/29
Oral Anabolic Steroid 95 kB	#20600	2008/09/29
Part D Safety Net 61 kB	#20740	2008/09/29
Plavix 35 kB	#20715	2008/10/29
Provigil 106 kB	#20710	2008/09/29
Rheumatoid/Crohns 68 kB	#20900	2008/09/29
Sedative Hypnotics 197 kB	#30110	2009/01/06
Sensipar 98 kB	#30115	2008/09/29
Subjective Global Assessment (SGA) 26 kB		2005/10/05
Symlin 123 kB	#301501	2008/09/29
Synagis Respigam 78 kB	#30120	2008/12/12
Synvisc 113 kB	#30130	2008/09/29
Syringe Filling 60 kB	#30140	2008/09/29
Vivitrol 97 kB	#3400	2008/09/29
Zyvox 134 kB	#30820	2008/09/29

Additional PA News & Info

Name	Description	Date
Erectile Dysfunction CMS Letter 80 kB		2006/01/03
Open-ended PA List 36 kB		2005/08/30
Mini-Mental State Exam 126 kB		2004/06/07
Average Determination - First Quarter 2008 96 kB		2009/01/08
PAs by Category Description - First Quarter 2008 87 kB		2009/01/08
PA Statistics by PDL Category (Approval Rate Descending) - First Quarter 2008 74 kB		2009/01/08
PA Statistics by PDL Category - First Quarter 2008 76 kB		2009/01/08
PA Statistics by PDL Category ( PA Descending) - First Quarter 208 74 kB		2009/01/08
Average Determination - Second Quarter 2008 115 kB		2009/01/08
PAs by Category Description - Second Quarter 2008 86 kB		2009/01/08
PA Statistics by PDL Category (Approval Rate Descending) - Second Quarter 2008 73 kB		2009/01/08
PA Statistics by PDL Category - Second Quarter 2008 149 kB		2009/01/08
PA Statistics by PDL Category ( PA Descending) - Second Quarter 208 73 kB		2009/01/08
Average Determination - Third Quarter 2008 93 kB		2009/01/08
PAs by Category Description - Third Quarter 2008 106 kB		2009/01/08
PA Statistics by PDL Category (Approval Rate Descending) - Third Quarter 2008 93 kB		2009/01/08
PA Statistics by PDL Category - Third Quarter 2008 94 kB		2009/01/08
PA Statistics by PDL Category ( PA Descending) - Third Quarter 208 92 kB		2009/01/08