Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
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.)
If you cannot view a file, please download the appropriate free plug-in from the links below.
| Name | Description | Date |
|---|---|---|
| Opiate Limits PA 31.5 KB | #10300 | 2013/01/17 |
| 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 |
| Platelet Aggregation Inhibitors 46.5 KB | #20715 | 2012/08/06 |
| Pradaxa 54 KB | #20725 | 2012/08/06 |
| Subjective Global Assessment (SGA) 69 KB | 2012/06/05 | |
| Vivitrol 34 KB | #30400 | 2011/10/05 |
| WIC MaineCare PA Form 202.97 KB | All children under five are required to complete the PA form for medical necessity | 2011/10/04 |
| PA Submission Instructions 66.9 KB | 2011/09/19 | |
| Drug Drug Interaction 33 KB | #10400 | 2011/08/22 |
| Antipsychotic 39 KB | #10130 | 2011/07/22 |
| Proton Pump Inhibitors 42.5 KB | #20720 | 2011/07/22 |
| Provigil 41.5 KB | #20710 | 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 40.5 KB | #10610 | 2011/05/26 |
| Antibacterial Antibiotics 36.5 KB | #30820 | 2011/04/29 |
| Cox II Inhibitors 36 KB | #10310 | 2011/04/20 |
| Dose Consolidation 35 KB | #10420 | 2011/03/01 |
| MS Agents 51 KB | #20430 | 2010/12/03 |
| Botox - Myobloc 52.5 KB | #10210 | 2010/12/03 |
| Byetta 36 KB | #10230 | 2010/12/03 |
| Hyaluronic Acid Derivatives 49 KB | #30130 | 2010/11/05 |
| Narcotics 45.5 KB | #20510 | 2010/01/15 |
| Amevive 35 KB | #20910 | 2009/07/09 |
| Med Watch Form 124.51 KB | 2009/05/08 | |
| Non Sedating Antihistimines 35.5 KB | #20530 | 2009/05/08 |
| Sedative Hypnotics 34.5 KB | #30110 | 2009/01/06 |
| Syringe Filling 31 KB | #30140 | 2008/09/29 |
| Miscellaneous Non Preferred 34 KB | #20420 | 2008/09/29 |
| Antifungals 41 KB | #10120 | 2008/09/29 |
| Multi Antipsychotic - Clinical PA 34.5 KB | #20440 | 2008/09/29 |
| Brand Drugs 55 KB | #10220 | 2008/09/29 |
| Ondansetron 37 KB | #20610 | 2008/09/29 |
| Oral Anabolic Steroid 32.5 KB | #20600 | 2008/09/29 |
| EPO 38 KB | #10520 | 2008/09/29 |
| Rheumatoid/Crohns 33.5 KB | #20900 | 2008/09/29 |
| Four (4) Brand PA Form 34.5 KB | #10600 | 2008/09/29 |
| Fuzeon 35 KB | #10620 | 2008/09/29 |
| Sensipar 33 KB | #30115 | 2008/09/29 |
| Symlin 45 KB | #30150 | 2008/09/29 |