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Massachusetts Medicaid Prior (Rx) Authorization Form

Massachusetts Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

Massachusetts MassHealth prior authorization form requests Medicaid coverage for a non-preferred drug prescription. A prescription prior authorization form is necessary when a preferred alternative therapy has either failed in treatment, is contraindicated, or there is a special indication preventing this medication from being a viable option for a specific patient. The Massachusetts (MassHealth) Preferred Drug List can be found below.

Fax – 1 (877) 208-7428

Phone – 1 (800) 745-7318

MassHealth Drug List