1 (continued on next page)
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)
click to sign
signature
click to edit
![]()
