MassHealth Prior (Rx) Authorization Form

Updated December 31, 2021

A MassHealth Prior Authorization Form is used by a medical office when they wish to request coverage from MassHealth for a prescription not listed on the formulary on behalf of a patient. This action is usually taken when other medications have been unsuccessful in treating their patient for a particular diagnosis. By filling and submitting this form, the medical professional may be able to secure coverage of a particular prescription for their patient.

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Forms

How to Write

Step 1 – In the Member information section, you must enter the patient’s full name, their MassHealth member ID, their date of birth, their gender, and their place of residence.

Step 2 – In Medication information, provide the drug name requested, the drug’s dose, frequency, duration, and NDC or service code. Then, enter the relevant diagnosis and/or indication.

Step 3 – Next, complete Section I of the form by indicating the billing method and whether the patient has tried other medications for this condition. If they have taken any other medication, you will either need to provide the drug name, dates of use, dose, frequency, and the reason for failure. If the patient has not taken any other medications for this condition, you will need to provide a justification for this request, attaching a separate letter of explanation if necessary.

Step 4 – In Section II, you will need to explain the medical necessity of the requested drug, list all medications that the patient is currently taking, and describe the studies and tests performed on the patient to determine this diagnosis. If there is any other information that should be included, write it in the Other pertinent information field.

Step 5 – If there are other “preferred drug products” designated for this class of drug, explain your justification for prescribing this non-preferred drug product in Section III.

Step 6 – Beneath Prescriber information, enter your full name, your NPI, your MassHealth provider ID, your DEA number, an office contact name, your complete office address, your work email address, your office telephone number, and your office fax number.

Step 7 – At the bottom of the page, you must provide your signature, your printed name, and the date.