To submit a request:
- Select and print the proper form from the list below
- Fill out the form completely
- Fax the completed form to us at 1-888-879-6938
- Acute Migraine
- Antibacterial Antibiotics
- Antifungals
- Antipsychotics
- Botulinum
- Brand Drugs
- Buprenorphine Extended Release
- Dose Consolidation
- Drug Drug Interaction
- EPO
- Granulocyte Colony Stimulating Factor
- Growth Hormone
- Hepatitis C Treatment
- Hyaluronic Acid Derivatives
- Med Watch Form
- Miscellaneous Non Preferred
- MS Agents
- Multi Antipsychotic - Clinical PA
- Narcotics
- Non Sedating Antihistimines
- Opiate Limits
- PA Submission Instructions
- Platelet Aggregation Inhibitors
- Proton Pump Inhibitors
- Provigil
- Psoriasis Biologicals
- Rheumatoid/Crohns
- Sedative Hypnotics
- Semaglutide/MACE PA Form
- Sensipar
- Subjective Global Assessment (SGA)
- Suboxone / Buphrenophine
- Synagis RSV Prevention
- Syringe Filling
- WIC MaineCare PA Form