Prior authorization request for MaineCare-covered hearing aids.
- Completed by
- Audiologist or ordering provider
- Issued by
- Maine Department of Health and Human Services, Office of MaineCare Services
- Format
- Language
- English
MaineCare Form 20420: Non-Preferred Drug PA Request
MaineCare uses form 20420 for prior authorization of non-preferred drugs and other drugs subject to PA that do not have their own form. Prescribers meet it when a MaineCare or MEDEL member needs a drug outside the preferred list. The form asks why the drug is necessary, which preferred alternatives were tried, and why each untried one is unsuitable, with supporting office notes attached.
Who completes it
The prescriber completes the member, prescriber, drug and medical necessity sections and signs; the signature must match the provider listed. A pharmacy-use-only line holds the pharmacy NPI, NABP number and NDC.
Submitting and payment
- How to submit it
- Fax the form with supporting office notes to the MaineCare pharmacy prior authorization unit at the number printed on it; a phone line is also listed. Illegible, incorrect or incomplete forms are returned.
Good to know
- Only one drug per form, completed in black or blue ink, and use the MaineCare member ID, not the Medicare number.
- Days supply is limited to 34 days at retail or 90 days by mail order, entered with strength, dosing instructions, quantity and refills.
- Oral nutritional supplement requests need a copy of the SGA form and WIC eligibility; Alzheimer medication requests need a copy of the MMSE.
- MaineCare is fee-for-service with no managed care plans, so this form covers every member. Its header reads Form # 20420, revision 09.08.
Get the official form
Download the current version from the source each time; forms change without notice.
MaineCare/MEDEL Prior Authorization Form: Miscellaneous/Non-Preferred Drugs Subject to PA
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Can I request two drugs on MaineCare form 20420?
No. The form states one drug per form only. Submit a separate 20420 for each drug, and check first whether the drug has its own MaineCare form; about 34 drug- or class-specific forms exist, plus a Brand Drugs form (20220).
What is the chart documentation exception on form 20420?
One of two signature options lets the prescriber certify that the information is accurate and that the required medical records are physically or electronically accessible and meet the posted PDL criteria. Falsification can bring sanctions, including recoupment, under MaineCare Benefits Manual Chapter I, Sections 1.16 and 1.19.