Massachusetts Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Download and open the PDF version of the prior authorization form.

Step 2 – Begin filling out the form by entering the patient’s full name, MassHealth member ID number, date of birth, gender, and place of residency into the “Member information” section.

Step 3 – In the “Medication information” section, you will need to supply the drug name, the dose, frequency, and duration, the drug NDC or service code, and the related diagnosis or indication.

Step 4 – In “Section I,” you will need to indicate the following using the checkboxes and, depending upon your answers, provide the requisite additional information:

  • Whether the request is for pharmacy or in-office billing
  • Whether the member has tried other medications to treat this condition
  • If the member experienced any adverse reaction, inadequate response, or “other”

Step 5 – In “Section II,” you will be asked to explain the medical necessity of the requested drug, list any and all current medications the patient is taking, describe studies and laboratory tests that support your justifications, and any other information that is relevant to your request.

Step 6 – In “Section III,” you must explain why you are making this request instead of using a preferred drug for treatment.

Step 7 – In the “Prescriber information” section, you will need to provide the following information into the indicated fields:

  • Your full name
  • NPI number
  • Individual MH provider ID
  • DEA Number
  • Office contact name
  • Complete address
  • E-mail address
  • Telephone number
  • Fax number

Step 8 – Type your name and the date before printing off the form. Once printed, sign your name where it says “Signature required.” You may now fax your request to the appropriate directory, making sure to attach any supporting medical documents.