PA - Prior Authorization Forms
(click column headers to sort)Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-888-879-6938
- Log in to the MaineCare Rx Portal @ www.mainecarerxportal.org and submit PA's electronically
For answers to frequently asked questions and additional information on submitting a PA: PA Submission Instructions
(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 |
PA Submission Instructions
219 kB
|
2011/09/19 | |
Acute Migraine
631 kB
|
#10110 | 2011/06/17 |
|
Amevive
134 kB
|
#20910 | 2009/07/09 |
|
Antibacterial Antibiotics
37 kB
|
#30820 | 2011/04/29 |
|
Antifungals
239 kB
|
#10120 | 2008/09/29 |
|
Antipsychotic
117 kB
|
#10130 | 2011/07/22 |
|
Botox - Myobloc
281 kB
|
#10210 | 2010/12/03 |
|
Brand Drugs
164 kB
|
#10220 | 2008/09/29 |
|
Byetta
143 kB
|
#10230 | 2010/12/03 |
|
Cox II Inhibitors
169 kB
|
#10310 | 2011/04/20 |
|
Dose Consolidation
136 kB
|
#10420 | 2011/03/01 |
|
Drug Drug Interactions
128 kB
|
#10400 | 2011/08/22 |
|
EPO
110 kB
|
#10520 | 2008/09/29 |
|
Flumist
121 kB
|
#10610 | 2011/05/26 |
|
Four (4) Brand PA Form
103 kB
|
#10600 | 2008/09/29 |
|
Fuzeon
67 kB
|
#10620 | 2008/09/29 |
|
Growth Hormone
248 kB
|
#10710 | 2011/07/22 |
|
Hyaluronic Acid Derivatives
211 kB
|
#30130 | 2010/11/05 |
|
Med Watch Form
269 kB
|
2009/05/08 | |
|
Miscellaneous Non Preferred
96 kB
|
#20420 | 2008/09/29 |
|
MS Agents
284 kB
|
#20430 | 2010/12/03 |
|
Multi Antipsychotic - Clinical PA
102 kB
|
#20440 | 2008/09/29 |
|
Narcotics
289 kB
|
#20510 | 2010/01/15 |
|
Neupogen Leukine
138 kB
|
#20520 | 2011/05/27 |
|
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 |
|
Plavix
81 kB
|
#20715 | 2010/03/04 |
|
Proton Pump Inhibitors
283 kB
|
#20720 | 2011/07/22 |
|
Provigil
148 kB
|
#20710 | 2011/07/22 |
|
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
247 kB
|
#30120 | 2011/10/03 |
|
Syringe Filling
60 kB
|
#30140 | 2008/09/29 |
|
Vivitrol
165 kB
|
#3400 | 2011/10/05 |
|
WIC MaineCare PA Form
3 MB
|
All children under five are required to complete the PA form for medical necessity | 2011/10/04 |
