eForms Logo

Maine Medicaid Prior (Rx) Authorization Form

Maine Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

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