CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Massachusetts Standard Medication Prior Authorization Form - Coverage Criteria

Standardized medication prior authorization request form for providers to submit initial and renewal requests, quantity exceptions, step therapy, formulary exceptions, and specialty drug requests to Blue Cross Blue Shield - Massachusetts. Affects prescribers and facilities requesting medication coverage or administratively billed drugs for BCBSMA members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMassachusetts Standard Medication Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with diagnosis (ICD codes), medication details, prior therapies tried/failed, and required clinical documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections A–Fform sections included

Fax: 1-888-641-5355administrative routing

Prior auth / step therapy / exceptionsrequest types supported

Prior therapies & labsclinical info requested

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Coverage Determination and Requirements

General coverage determination

Coverage determination is based on completion of required fields and attached supporting clinical documentation demonstrating medical necessity.

Submission requirements: Provider must submit completed form fields for patient information, prescriber information, and medication details (strength, dose/schedule, quantity, length of therapy, date therapy initiated); include primary diagnosis and ICD codes, pertinent comorbidities, drug allergies, height/weight, and pertinent concurrent medications.

Supports payer medical necessity review

Prior therapy and rationale: Provide documentation of previous therapies tried/failed (drug name, strength, dosing, dates, description of adverse reaction or failure), state whether contraindications to alternatives exist, and whether nonpharmacologic therapies were attempted with details.

Used to assess appropriateness of requested therapy

Professionally administered medication details (if applicable): For professionally administered medications include start/end dates, servicing prescriber/facility name and address, servicing provider NPI/Tax ID, billing provider name and NPI, CPT code(s), number of visits and units, and indicate if request is reauthorization.

Required for billing and medically necessary administration

Supporting clinical data: Attach relevant laboratory values with date performed and any additional information pertinent to the request; if a renewal request, include documentation of clinical improvement while on therapy.

Clinical data used to establish medical necessity

Complete attestation and routing: Indicate request type (initial or continuation/renewal) and reason for request (prior authorization, step therapy, formulary exception, quantity exception, specialty drug, etc.); check expedited review if applicable and attest to urgency.

Ensures correct processing pathway

This standardized medication prior authorization form may not be accepted by all payers. Some plans (for example, certain Medicare or Medicaid programs) might not accept this form for requests and providers should verify plan-specific submission requirements before using it.

Submission, Documentation, and Administrative Actions

Prior Authorization

Prior Authorization Required

Prior Authorization is required for medications listed on this form. For professionally administered medications (including buy & bill), fax requests to 1-888-641-5355 (BCBSMA employees fax to 1-617-246-4013). Completing this form and including all required fields helps avoid processing delays.

Fax professionally administered medication requests to 1-888-641-5355 (BCBSMA employees: 1-617-246-4013).
Indicate request type: Initial or Continuation/Renewal.
Select reason(s) for request: Prior Authorization, Step Therapy, Formulary Exception, Quantity Exception, Specialty Drug, or Other.

Step Therapy

Step Therapy Documentation

Document prior steps of therapy and nonpharmacologic therapies tried. The form must list previous medications, dosing, dates, reasons for discontinuation or adverse reactions, and whether samples were used. If step therapy is applicable, provide documentation of step failures or contraindications.

List prior therapies with drug name, strength, dosing, start/stop dates, and reason for failure or adverse reaction.
Indicate if contraindications to alternatives exist and provide details.
Document nonpharmacologic therapies tried and describe outcomes.

Documentation Required

Required Documentation to Support Medical Necessity

Provide complete clinical and medication-specific documentation to support medical necessity. Include medication strength, quantity, dosing schedule, length and start date of therapy, DAW rationale if applicable, compounding ingredient list, and citations for off-label use. Attach peer-reviewed literature when applicable.

Medication details: strength, quantity, dosing schedule, length of therapy, and start date.
DAW: indicate if Dispense As Written is specified and provide rationale.
For compounds: list all ingredients.
For off-label use or compounds: include citation(s) to peer-reviewed literature and any supporting documentation.

Denial Risk

Incomplete Clinical Information — Risk of Denial

Complete and accurate patient clinical information is required. Missing primary diagnosis, ICD-10 codes, comorbidities, relevant labs, prior therapies, or concurrent medications may result in denial or processing delays. For renewals, indicate clinical improvement while on therapy and supply recent lab results.

Include primary diagnosis and corresponding ICD-10 code(s).
List pertinent comorbidities and concurrent medications.
Provide drug allergies, height, weight, and any opioid-management documentation if relevant.
Attach recent relevant lab values with dates.
For renewals, document clinical improvement or lack thereof while on therapy.

Form Purpose and Scope

This form gathers both clinical and administrative information used to determine medical necessity for medication coverage. It requests patient diagnosis and ICD codes, prior therapy history (including dates, dosing, and reasons for discontinuation or failure), medication details (strength, dose, schedule, length of therapy, start date), and, for professionally administered drugs, servicing provider/facility and CPT/unit information.

The form also captures supporting clinical data needed for initial and renewal reviews: documentation of prior therapies tried/failed or contraindicated (step therapy), relevant laboratory values, and for renewals an assessment of treatment response or improvement. Additionally, it collects compound ingredient lists and literature justification for off‑label use when applicable.

Key Definitions

Expedited Review/Urgent Request — prescriber attestation

DefinitionA request type that the prescriber can check when the request meets the definition and criteria for expedited review and is urgent.

Prescriber attestationBy checking the 'Expedited Review/Urgent Request' box the prescriber attests that the request meets the definition and criteria for expedited review and is urgent.

Where indicatedThe form includes a checkbox labeled 'Expedited Review/Urgent Request' for the prescriber to select when applicable.

PurposeSignals to the payer that the request requires expedited handling because delaying care could seriously jeopardize the patient's health or ability to regain maximum function.

DocumentationAttestation is made directly on the form via the checkbox; no additional text field for justification is provided on this checkbox line (supporting clinical documentation should accompany the request).

Initial Request Requirements

Initial therapy requirements

Initial requests must include diagnosis, prior therapies, and rationale for chosen therapy.

Initial request requirements: Provide primary diagnosis and ICD code(s), complete medication details (name, strength, dosing schedule, quantity, length of therapy, date therapy initiated), and rationale for the selected medication (including DAW rationale if applicable).

Supports initial prior authorization review

Prior therapies: List prior therapies tried with drug name, strength, dosing, dates prescribed/stopped, and description of adverse reaction or reason for failure; indicate if samples were used.

Used to document step therapy or prior treatment failure

Alternatives and nonpharmacologic measures: Document contraindications to alternative therapies OR provide details of nonpharmacologic therapies attempted, if applicable.

Helps justify choice of requested therapy

Continuation / Renewal Requirements

Continuation/Renewal requirements

For continuation or renewal requests the form requires documentation of patient response and relevant labs.

Renewal documentation: Indicate whether the patient has shown improvement in the related condition while on therapy and provide a description of improvement; include start date and prior authorization identifier if applicable.

Used to assess ongoing medical necessity

Relevant laboratory monitoring: Provide relevant lab names, values, and dates performed to support continued therapy.

Laboratory evidence required when applicable to monitor safety or efficacy

Current medication status: State whether the patient is currently being treated with the requested drug and provide the date therapy was started; include any interim adverse reactions or changes in concurrent medications.

Ensures up-to-date treatment and safety information is available

Step Therapy Documentation

Drug name	Strength	Dosing / schedule	Start date	Stop date	Reason for discontinuation / failure (including adverse reaction)	Sample given?
[Enter drug name]	[Enter strength]	[Enter dosing and schedule]	[Enter start date]	[Enter stop date]	[Enter reason for discontinuation or failure, include adverse reaction details if applicable]	[Check if sample was provided: Yes / No]
[Enter drug name]	[Enter strength]	[Enter dosing and schedule]	[Enter start date]	[Enter stop date]	[Enter reason for discontinuation or failure, include adverse reaction details if applicable]	[Check if sample was provided: Yes / No]
[Enter drug name]	[Enter strength]	[Enter dosing and schedule]	[Enter start date]	[Enter stop date]	[Enter reason for discontinuation or failure, include adverse reaction details if applicable]	[Check if sample was provided: Yes / No]

Professionally Administered Medications / Infusion Centers

Billing Rule

Infusion center / servicing provider information required

For professionally administered medications, complete the section for start/end dates and supply the servicing prescriber/facility name, address, and servicing provider NPI/Tax ID; also provide billing provider name and NPI and the CPT code/units for the service.

Indicate if servicing prescriber/facility is the same as the prescribing clinician.
Provide CPT code, number of visits, and number of units to support billing.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMassachusetts Standard Medication Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with diagnosis (ICD codes), medication details, prior therapies tried/failed, and required clinical documentation to support medical necessity.

SourceLink

On This Page

ICD codes	Primary diagnosis and related ICD codes to be provided by the prescriber
CPT Code	CPT code for professionally administered medications — providers to supply

OpenPayer

Massachusetts Standard Medication Prior Authorization Form - Coverage Criteria

Coverage Determination and Requirements

Diagnosis and Procedure Codes

Submission, Documentation, and Administrative Actions

Form Purpose and Scope

Key Definitions

Initial Request Requirements

Continuation / Renewal Requirements

Step Therapy Documentation

Professionally Administered Medications / Infusion Centers