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Prior Authorization (PA) Helpdesk (for Provider PA inquiries): (p) 888-445-0497 (f) 888-879-6938

PA - Prior Authorization Forms Archive

Name Description Date
Synagis RSV Prevention 191.4 KB #30120 2019/09/27
Suboxone/Buprenorphine 62.5 KB #20100 2019/02/05
Synagis RSV Prevention 27.33 KB #30120 2018/11/06
Hepatitis C Treatment 151.48 KB # 10700 2018/09/28
Hepatitis C Treatment 283.42 KB #10700 As of January 1, 2018 2017/12/29
Hepatitis C Treatment 283.85 KB #10700 2017/12/15
Synagis RSV Prevention 77 KB #30120 2017/11/06
Botox - Myobloc 79 KB #10210 2017/07/27
Botox - Myobloc 88 KB #10210 2017/02/06
Opiate Limits 60.5 KB #10300 2017/01/27
Botox - Myobloc 87 KB #10210 2017/01/19
Antipschotics 69.5 KB #10130 2016/12/31
Synagis RSV Prevention 45 KB #30120 2016/11/03
Hepatitis C Treatment Form 266.84 KB #10700 2016/10/27
Hepatitis C Treatment Form 158.09 KB #10700 2016/09/29
Narcotics 40 KB #20510 2016/08/16
Hepatitis C Treatment Form 137 KB #10700 2016/05/27
Proton Pump Inhibitors 39 KB #20720 2016/02/11
Botox - Myobloc 50 KB #10210 2015/12/21
Hepatitis C Treatment Form 129.5 KB #10700 2015/12/01
Synagis (RSV Prevention) 44 KB #30120 2015/10/29
Hepatitis C Treatment Form 105 KB 2015/03/23
Hepatitis C Treatment Form 105 KB #10700 2015/03/03
Hepatitis C Treatment 85 KB #10700 2015/01/16
Synagis (RSV Prevention) 44 KB #30120 2014/11/10
Antipsychotic 45 KB #10130 2014/06/02
Sovaldi 73 KB #10700 2014/05/05
Hyaluronic Acid Derivatives 49.5 KB #30130 2014/04/21
Suboxone.Buprenorphine Restart 34.5 KB #10100 2014/04/21
Suboxone.Buprenorphine Continuation 38 KB #10200 2014/04/21
MS Agents 46 KB #20430 2014/04/21
Proton Pump Inhibitors 39 KB #20720 2014/01/16
Hyaluronic Acid Derivatives 49.5 KB #30150 2013/12/17
Byetta-Victoza 36.5 KB #10230 2013/11/22
Synagis (RSV Prevention) 41 KB #30120 2013/10/25
Narcotics 40 KB #20510 2013/09/26
Synvisc 49.5 KB #30130 2013/07/25
Byetta-Victoza-Bydureon 37.5 KB #10230 2013/07/23
Opiate Limits PA 31.5 KB #10300 2013/01/17
Narcotic Limits 31.5 KB #10300 2013/01/14
Synagis (RSV Prevention) 41 KB #30120 2013/01/11
Suboxone.Buprenorphine Continuation 37 KB #10200 2012/12/06
Suboxone.Buprenorphine Restart 34 KB #10100 2012/12/06
Synagis 39.5 KB #30120 2012/10/29
Platelet Aggregation Inhibitors 46.5 KB #20715 2012/08/06
Subjective Global Assessment (SGA) 69 KB 2012/06/05
Vivitrol (copy) 34 KB #30400 2011/10/05
Vivitrol 34 KB #30400 2011/10/05
WIC MaineCare PA Form (copy) 1.4 MB All children under five are required to complete the PA form for medical necessity 2011/10/04
Synagis (copy) 45 KB #30120 2011/10/03
Synagis 39.5 KB #30120 2011/10/03
PA Submission Instructions 66.9 KB 2011/09/19
Proton Pump Inhibitors (copy) 41.5 KB #20720 2011/07/22
Proton Pump Inhibitors 42.5 KB #20720 2011/07/22
Provigil (copy) 38 KB #20710 2011/07/22
Provigil 41.5 KB #20710 2011/07/22
Antipsychotic 39 KB #10130 2011/07/22
Growth Hormone (copy) 42.5 KB #10710 2011/07/22
Growth Hormone 44.5 KB #10710 2011/07/22
Acute Migraine 57 KB #10110 2011/06/17
Neupogen Leukine 36 KB #20520 2011/05/27
Flumist (copy) 41 KB #10610 2011/05/26
Proton Pump Inhibitors (copy) 41 KB #20720 2011/04/29
Vivitrol (copy) 32 KB #30400 2011/04/29
Antipsychotic (copy) 39 KB #10130 2011/04/29
Cox II Inhibitors (copy) 36 KB #10310 2011/04/20
Cox II Inhibitors 36 KB #10310 2011/04/20
Dose Consolidation (copy) 35 KB #10420 2011/03/01
MS Agents 51 KB #20430 2010/12/03
Botox - Myobloc (copy) 45 KB #10210 2010/12/03
Byetta (copy) 39 KB #10230 2010/12/03
Botox - Myobloc 52.5 KB #10210 2010/12/03
Byetta 36 KB #10230 2010/12/03
MS Agents (copy) 45.5 KB #20430 2010/12/03
Hyaluronic Acid Derivatives (copy) 48.5 KB #30130 2010/11/05
Hyaluronic Acid Derivatives 49 KB #30130 2010/11/05
Acute Migraine (copy) 50.5 KB #10110 2010/10/15
Proton Pump Inhibitors (copy) 40 KB #20720 2010/10/08
Synagis (copy) 42.5 KB #30120 2010/10/01
Cox II Inhibitors (copy) 35 KB #10310 2010/08/06
Botox - Myobloc (copy) 47.5 KB #10210 2010/07/23
Antipsychotic (copy) 39 KB #10130 2010/07/22
Neupogen Leukine (copy) 35 KB #20520 2010/06/15
Proton Pump Inhibitors (copy) 40 KB #20720 2010/05/11
Acute Migraine (copy) 50 KB #10110 2010/04/02
MS Agents (copy) 47 KB #20430 2010/03/04
Acute Migraine (copy) 50 KB #10110 2010/03/04
Plavix (copy) 35 KB #20715 2010/03/04
Narcotics 45.5 KB #20510 2010/01/15
Narcotics (copy) 42 KB #20510 2010/01/14
Amevive 35 KB #20910 2009/07/09
Sedative Hypnotics 34.5 KB #30110 2009/01/06
Dosage Strength 31 KB #10410 2008/09/29
Ondansetron 37 KB #20610 2008/09/29
Antifungals 41 KB #10120 2008/09/29
Rheumatoid/Crohns 33.5 KB #20900 2008/09/29
Brand Drugs 55 KB #10220 2008/09/29
Symlin 45 KB #30150 2008/09/29
Zyvox 34.5 KB #30820 2008/09/29
EPO 38 KB #10520 2008/09/29
Four (4) Brand PA Form 34.5 KB #10600 2008/09/29
Fuzeon 35 KB #10620 2008/09/29
Part D Safety Net 31.5 KB #20740 2008/09/29
Subjective Global Assessment (SGA) 26.5 KB 2005/10/05