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

Prior Authorization Forms

Name Description Date
Hyaluronic Acid Derivatives 44.5 KB #30130 2022/07/08
Hepatitis C Treatment 301.12 KB #10700 2022/06/28
Synagis RSV Prevention 190.75 KB #30120 2021/10/19
Suboxone/Buprenorphine 82.45 KB #20100 2021/07/19
Narcotics 42 KB #20510 2021/04/29
Antibacterial Antibiotics 51 KB #30820 2020/09/23
Antipsychotics 65.5 KB #10130 2020/07/24
PA Submission Instructions 180.78 KB 2020/02/25
WIC MaineCare PA Form 166.17 KB All children under five are required to complete the PA form for medical necessity 2019/12/18
Proton Pump Inhibitors 40.5 KB # 20720 2019/05/24
Brand Drugs 54 KB #10220 2019/02/07
Granulocyte Colony Stimulating Factor 34.5 KB #20520 2019/01/17
Botox - Myobloc 79 KB #10210 2017/11/03
Opiate Limits 61 KB #10300 2017/03/17
MS Agents 83 KB #20430 2017/01/19
Cox II Inhibitors 32.5 KB #10310 2016/05/23
Provigil 42 KB #20710 2015/11/20
Subjective Global Assessment (SGA) 69 KB 2014/09/02
Antifungals 38 KB #10120 2014/04/21
Sedative Hypnotics 32 KB #30110 2014/04/21
Growth Hormone 40 KB #10710 2014/01/16
Psoriasis Biologicals 31.5 KB #20910 2014/01/16
Rheumatoid/Crohns 31 KB #20900 2014/01/16
Acute Migraine 51.5 KB #10110 2013/07/25
EPO 46 KB #10520 2013/07/25
Platelet Aggregation Inhibitors 47.5 KB #20715 2013/06/21
Pradaxa 54 KB #20725 2012/08/06
Drug Drug Interaction 33 KB #10400 2011/08/22
Flumist 40.5 KB #10610 2011/05/26
Dose Consolidation 35 KB #10420 2011/03/01
Med Watch Form 124.51 KB 2009/05/08
Non Sedating Antihistimines 35.5 KB #20530 2009/05/08
Miscellaneous Non Preferred 34 KB #20420 2008/09/29
Multi Antipsychotic - Clinical PA 34.5 KB #20440 2008/09/29
Sensipar 33 KB #30115 2008/09/29
Syringe Filling 31 KB #30140 2008/09/29