Get Mainecare Pdl

Filling out the Mainecare Pdl is an important step in managing prior authorization requests for medications like . This guide provides clear and detailed instructions to help you navigate and complete the form efficiently, ensuring you understand each section and field.

Follow the steps to complete the Mainecare Pdl accurately.

1. Press the ‘Get Form’ button to access the Mainecare Pdl form and open it in your preferred editor.
2. Begin by filling out the Member Information section. Enter the patient's name, cardholder ID, date of birth, and the address details, including city, state, and zip code.
3. In the Provider Information section, input the provider's name, DEA number, and their contact information, including phone and fax numbers.
4. Next, complete the Pharmacy Information section by providing the pharmacy name, address, and phone number.
5. Proceed to the Criteria for Approval section. Indicate the dosage of by checking either the 100mg or 200mg box.
6. Answer the age-related questions by selecting 'Yes' or 'No' for whether the patient is between 18 and 60 years old and for whether the patient is 60 years of age or older.
7. Identify any relevant diagnoses by checking all that apply in the list provided, such as familial adenomatous polyposis (FAP), acute pain, and others.
8. Further, answer the questions regarding the patient’s risk for NSAID-induced gastrointestinal adverse events, and whether they are currently on a proton pump inhibitor or aspirin therapy.
9. Note any allergic reactions by checking all applicable options for aspirin, NSAIDs, and sulfonamides.
10. Finally, the provider must sign and date the form. Ensure all fields are complete before submission.
11. Fax the completed form to the designated number at (866) 284-4509.
12. After faxing, ensure you keep a copy for your records. You may also want to follow up to confirm receipt.

Complete your Mainecare Pdl form online today for a smoother prior authorization process.