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Massachusetts Collaborative — Massachusetts Standard Form for Medication Prior Authorization Requests May 2016 (version 1.0)
MASSACHUSETTS STANDARD FORM FOR MEDICATION
PRIOR AUTHORIZATION REQUESTS
*Some plans might not accept this form for Medicare or Medicaid requests.
This form is being used for:
Check one:
Initial Request
Continuation/Renewal Request
Reason for request (check all that apply):
Prior Authorization, Step Therapy, Formulary Exception
Quantity Exception
Specialty Drug
Other (please specify):
Check if Expedited Review/Urgent Request:
(In checking this box, I attest to the fact that this request meets the
definition and criteria for expedited review and is an urgent request.)
A. Destination — Where this form is being submitted to; payers making this form available on their websites may prepopulate section A
Health Plan or Prescription Plan Name:
Health Plan Phone: Fax:
B. Patient Information
Patient Name: DOB:
Gender:
Male
Female
Unknown
Member ID #:
C. Prescriber Information
Prescribing Clinician: Phone #:
Specialty: Secure Fax #:
NPI #: DEA/xDEA:
Prescriber Point of Contact Name (POC) (if different than provider):
POC Phone #: POC Secure Fax #:
POC Email (not required):
Prescribing Clinician or Authorized Representative Signature:
Date:
D. Medication Information
Medication Being Requested:
Strength: Quantity:
Dosing Schedule: Length of Therapy:
Date Therapy Initiated:
Is the patient currently being treated with the drug requested?
Yes
No If yes, date started:
Dispense as Written (DAW) Specified?
Yes
No
Rationale for DAW:
E. Compound and Off Label Use
Is Medication a Compound?
Yes
No
If Medication Is a Compound, List Ingredients:
For Compound or Off Label Use, include citation to peer reviewed literature:
617.972.9409 (for coverage under the Medical Benefit)
Tufts Health Plan
888.884.2404
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Massachusetts Collaborative — Massachusetts Standard Form for Medication Prior Authorization Requests May 2016 (version 1.0)
F. Patient Clinical Information
*Please refer to plan-specific criteria for details related to required information.
Primary Diagnosis Related to Medication Request:
ICD Codes:
Pertinent Comorbidities:
If Relevant to This Request:
Drug Allergies:
Height: Weight:
Pertinent Concurrent Medications:
Opioid Management Tools in Place:
Risk assessment
Treatment Plan
Informed Consent
Pain Contract
Pharmacy/Prescriber Restriction
Previous Therapies Tried/Failed:
Previous Therapies
Drug Name Strength Dosing
Schedule
Date
Prescribed
Date
Stopped
Description of Adverse
Reaction or Failure
Check if
Sample
Are there contraindications to alternative therapies?
Yes
No
If yes, please list details:
Were nonpharmacologic therapies tried?
Yes
No
If yes, provide details:
Relevant Lab Values
Lab Name and Lab Value Date Performed Lab Name and Lab Value Date Performed
If renewal, has the patient shown improvement in related condition while on therapy?
Yes
No
N/A
If yes, please describe:
Additional information pertinent to this request:
Complete this section for Professionally Administered Medications (including Buy and Bill).
Start Date: End Date:
Servicing Prescriber/Facility Name:
Same as Prescribing Clinician
Servicing Provider/Facility Address:
Servicing Provider NPI/Tax ID #:
Name of Billing Provider:
Billing Provider NPI #:
Is this a request for reauthorization?
Yes
No
CPT Code: # of Visits: J Code: # of Units:
Providers should consult the health plans coverage policies, member benefits, and medical necessity guidelines to complete this form.
Providers may attach any additional data relevant to medical necessity criteria.
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