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Medicare Part D

Disclaimer

These publications are made available on the Office of MaineCare’s website as a public service. Although the Office of MaineCare Services makes an effort to provide accurate information, portions of text available may be incorrect or not current. Its accuracy is not certified by the Office of MaineCare Services, Maine Department of Health and Human Services or the State of Maine. The State, its agencies, officers and employees do not make any statutory, express or implied representation or warranty about the accuracy, reliability, completeness or timeliness of any information available and disclaim any liability for any losses resulting from any person’s reliance on such information. Any person relying on information contained within the text does so at the person’s own risk.

Medicare Part D Forms

Name Description Date
Medicare Part D Supplemental Form 40.73 KB 2011/04/28
Part B/D Combo Claim Form 90 KB 2008/10/20

Fox Rx Care - PA Forms and Related Information

Name Description Date
Lotronex 51.91 KB 2007/04/03
Alzheimers 62.31 KB 2007/04/03
Multiple Sclerosis 39.08 KB 2007/04/03
Amphetamine Products 53.88 KB 2007/04/03
Miscellaneous 36.24 KB 2007/04/03
Celebrex 124.59 KB 2007/04/03
Provigil 35.52 KB 2007/04/03
Diflucan 50.25 KB 2007/04/03
Rebetol 130.6 KB 2007/04/03
Elidel 83.64 KB 2007/04/03
Rebetron 131.88 KB 2007/04/03
Expedited Formulary Exception Request Form 69.33 KB 2007/04/03
Regranex 38.43 KB 2007/04/03
Expedited Redetermination Request Form 63.28 KB 2007/04/03
Retinoid 36.26 KB 2007/04/03
Formulary Exception Request Form 72.96 KB 2007/04/03
Roferon 38.01 KB 2007/04/03
Forteo 52.19 KB 2007/04/03
Standard Redetermination request Form 28.69 KB 2007/04/03
Fuzeon 93.22 KB 2007/04/03
Strattera 38.3 KB 2007/04/03
Growth Hormones 37.33 KB 2007/04/03
Tier Exception Request Form 36.92 KB 2007/04/03
Hematopoietic Agent 128.1 KB 2007/04/03
Zelnorm 36.59 KB 2007/04/03
Hepatitis B Vaccine 51.2 KB 2007/04/03
Zofran 35.96 KB 2007/04/03
Humira 62.24 KB 2007/04/03
IntronA 43.13 KB 2007/04/03

Cignature-Rx PA Forms and Related Information

Name Description Date
General PA Form 101.6 KB 2007/08/07

Wellcare - PA Forms and Related Information

Name Description Date
Redetermination 246.47 KB 2007/04/03
PDP Appeal Request 31 KB 2007/04/03
Medicare DER Form 73.57 KB 2007/04/03
Injectible 64.53 KB 2007/04/03
Model Coverage Determination Request Form 243.43 KB 2007/04/03

Rx Prescription Solutions - PA Forms and Related Information

Imedecs - PA Forms and Related Information

Name Description Date
Appeal Request Form 131.69 KB 2007/04/03

AARP - PA Forms and Related Information

Name Description Date
AARP Pharmacy NetworkFiles 90 KB 2007/08/07
AARP Formulary 6.21 MB 2007/08/07

Maximum - PA Forms and Related Information

Name Description Date
Reconsideration 253.74 KB 2007/04/03