Listed below are all the PA forms you will need in order to request drugs that require prior authorization.
To submit a request:
OR
Log in to the MaineCare Rx Portal @ https://providerportal.megov.changehealthcare.com/mepp/application/login.joi 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 |
|---|---|---|
| Sublocade 40 KB | #20200 | 2023/05/04 |
| Synagis RSV Prevention 190.81 KB | #30120 | 2022/10/25 |
| Hyaluronic Acid Derivatives 44.5 KB | #30130 | 2022/09/15 |
| Hepatitis C Treatment 301.12 KB | #10700 | 2022/06/28 |
| Antipsychotics 65.5 KB | #10130 | 2022/02/09 |
| Suboxone/Buprenorphine 82.45 KB | #20100 | 2021/07/19 |
| Narcotics 42 KB | #20510 | 2021/04/29 |
| Antibacterial Antibiotics 51 KB | #30820 | 2020/09/23 |
| 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 |
| 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 |
| 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 |
| Sensipar 33 KB | #30115 | 2008/09/29 |
| Syringe Filling 31 KB | #30140 | 2008/09/29 |
| Miscellaneous Non Preferred 34 KB | #20420 | 2008/09/29 |
| Multi Antipsychotic - Clinical PA 34.5 KB | #20440 | 2008/09/29 |
| 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 |