Maine Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

Maine MaineCare prior authorization form requests Medicaid coverage for a non-preferred drug prescription. In the content of this form, the healthcare provider must provide a thorough medical justification for making the request and their reasons for not prescribing a preferred drug. On this webpage, we have provided a fillable PDF version of this form for download. Once complete, this form should be faxed to the number found below.

Fax – 1 (888) 879-6938

Phone – 1 (888) 445-0497

Preferred Drug List – List of pre-approved drugs by the State

How to Write

Step 1 – Begin filling out your form by entering the following information into the indicated fields:

  • Patient’s Member ID number
  • Patient’s name
  • Patient’s date of birth
  • Patient’s address
  • Provider’s DEA
  • Provider’s NPI
  • Provider’s name
  • Provider’s phone number
  • Provider’s address
  • Provider’s fax number
  • Pharmacy name
  • Pharmacy Address
  • Pharmacy Phone number

If you are the dispensing pharmacist, provide the pharmacy NPI, NABP, and NDC.

Step 2 – Next, enter the drug’s name, strength, dosage instructions, quantity, days supply, and number of refills.

Step 3 – You must then answer the following three questions to provide justification for your request:

  • Why is the medication necessary for this member?
  • What other preferred alternatives were tried first? (if applicable)
  • Why did the preferred alternative(s) fail? (if applicable)

You must also include all supporting medical documentation and office notes along with your request.

Step 4 – Enter the date where it says, “Date of Submission.”

Step 5 – Print and sign the form. Once ready, fax the form and supporting documents to the fax number provided above.