Maine.gov
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

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
  4. 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.)

If you cannot view a file, please download the appropriate free plug-in from the links below.

Name Description Date
Subjective Global Assessment (SGA) 69 KB 2014/09/02
Antipsychotic 45 KB #10130 2014/06/02
Sovaldi 73 KB #10700 2014/05/05
Antifungals 38 KB #10120 2014/04/21
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
Sedative Hypnotics 32 KB #30110 2014/04/21
MS Agents 46 KB #20430 2014/04/21
PA Submission Instructions 85.04 KB 2014/01/24
Proton Pump Inhibitors 39 KB #20720 2014/01/16
Psoriasis Biologicals 31.5 KB #20910 2014/01/16
Rheumatoid/Crohns 31 KB #20900 2014/01/16
Homozygous FH 31 KB #10500 2014/01/16
Growth Hormone 40 KB #10710 2014/01/16
Synagis (RSV Prevention) 41 KB #30120 2013/10/25
Narcotics 40 KB #20510 2013/09/26
Acute Migraine 51.5 KB #10110 2013/07/25
EPO 46 KB #10520 2013/07/25
Byetta-Victoza-Bydureon 37.5 KB #10230 2013/07/23
Platelet Aggregation Inhibitors 47.5 KB #20715 2013/06/21
Opiate Limits PA 31.5 KB #10300 2013/01/17
Pradaxa 54 KB #20725 2012/08/06
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
Drug Drug Interaction 33 KB #10400 2011/08/22
Provigil 41.5 KB #20710 2011/07/22
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
Botox - Myobloc 52.5 KB #10210 2010/12/03
Med Watch Form 124.51 KB 2009/05/08
Non Sedating Antihistimines 35.5 KB #20530 2009/05/08
Oral Anabolic Steroid 32.5 KB #20600 2008/09/29
Sensipar 33 KB #30115 2008/09/29
Symlin 45 KB #30150 2008/09/29
Brand Drugs 55 KB #10220 2008/09/29
Syringe Filling 31 KB #30140 2008/09/29
Fuzeon 35 KB #10620 2008/09/29
Miscellaneous Non Preferred 34 KB #20420 2008/09/29
Multi Antipsychotic - Clinical PA 34.5 KB #20440 2008/09/29
Ondansetron 37 KB #20610 2008/09/29

Additional PA News & Info

Name Description Date
Erectile Dysfunction CMS Letter 79.37 KB 2006/01/03
Open-ended PA List 36 KB 2005/08/30
Mini-Mental State Exam 125.81 KB 2004/06/07