CurrentColorado Rocky Mountain Health PlansPolicy N/A

Massachusetts Prescription Prior Authorization Formopen_in_new

A standardized Massachusetts prior authorization form for medication requests used by health plans to collect patient, prescriber, medication, clinical, and billing information to support initial or renewal prior authorization, step therapy, quantity exception, specialty drug, or other medication coverage decisions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMassachusetts Prescription Prior Authorization Formopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete all relevant sections and may attach supporting documentation to demonstrate medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified.

1Standard Form Template

0Clinical Criteria Included (plan-specific required)

Policy overview

This is the Massachusetts standard form used by payers to collect consistent information for medication prior authorization requests. It is intended for use on initial or continuation/renewal requests and to support determinations such as prior authorization, step therapy, formulary exceptions, quantity exceptions, and specialty drug approvals. The form gathers patient, prescriber, medication, clinical, and billing information to evaluate medical necessity and process coverage decisions.

Key metadata (document-level)"

Policy title (subject)Massachusetts Standard Medication Prior Authorization Request Form

PayerHealth Plan / Prescription Plan (specified by destination section)

Policy numberN/A

StatusCURRENT

Scope summaryA standardized Massachusetts prior authorization form for medication requests used by health plans to collect patient, prescriber, medication, clinical, and billing information to support initial or renewal prior authorization, step therapy, quantity exception, specialty drug, or other medication coverage decisions.

Document noteThis is a Massachusetts standardized template; some plans might not accept this form for Medicare or Medicaid requests and plan acceptance may vary.

Coverage stance & intended determinations

Coverage stance: informational. The form supports determinations including prior authorization, step therapy, formulary exception, quantity exception, specialty drug approval, and other medication decisions as indicated on the form. Form sections allow providers to indicate the nature of the request (e.g., Initial Request or Continuation/Renewal) and check reasons for the request (Prior Authorization/Step Therapy/Formulary Exception, Quantity Exception, Specialty Drug, or Other), and include an option to request an Expedited Review/Urgent Request with attestation.

Request Type and Reason

Form sections to indicate the nature of the request and applicable exceptions:

ANY of the following

Initial Request (checkbox)
Continuation/Renewal Request (checkbox)

Reason for request (check all that apply)

Prior Authorization, Step Therapy, Formulary Exception (checkbox)
Quantity Exception (checkbox)
Specialty Drug (checkbox)
Other (please specify) (checkbox + free text)

Expedited Review/Urgent Request

Expedited Review/Urgent Request (checkbox) with attestation that request meets definition and criteria for expedited review

Patient, prescriber, medication, clinical and billing data required

Patient, Prescriber, Medication, and Clinical Data Requirements

Form requires completion of the following patient- and medication-specific data to evaluate medical necessity:

ALL of the following

Patient identifying information: Patient name; DOB; gender; member ID
Prescribing clinician information: Prescribing clinician name; phone; specialty; secure fax; NPI; DEA/xDEA; prescriber point of contact name/phone/fax/email
Signature of prescribing clinician or authorized representative and date
Medication details: Medication name; strength; quantity; dosing schedule; length of therapy; date therapy initiated
Current treatment status: Is the patient currently being treated with the drug requested? (Yes/No). If yes, date started
Dispense as Written (DAW): DAW specified? (Yes/No) and rationale for DAW
Compound medication: Is medication a compound? (Yes/No); list ingredients if applicable; citation to peer-reviewed literature for compound or off-label use
Diagnosis/ICD codes: Primary diagnosis related to medication request and ICD codes
Comorbidities and concurrent meds: Pertinent comorbidities; drug allergies; height; weight; pertinent concurrent medications
Opioid management tools in place where relevant: risk assessment; treatment plan; informed consent; pain contract; pharmacy/prescriber restriction
Previous therapies tried/failed with details: drug name; strength; dosing; dates prescribed/stopped; adverse reaction or failure; whether sample
Contraindications to alternatives: Are there contraindications to alternative therapies? (Yes/No) and details if yes
Nonpharmacologic therapies: Were nonpharmacologic therapies tried? (Yes/No) and details if yes
Relevant lab values with dates
Renewal improvement question: For renewals: Has the patient shown improvement in related condition while on therapy? (Yes/No/N/A) and description if yes
Additional information pertinent to this request (free text)

Professionally Administered Medications / Buy and Bill section

Additional fields required when request is for a professionally administered medication:

ALL of the following

Administration dates: Start date and end date of administration
Servicing prescriber/facility name and indication if same as prescribing clinician
Servicing provider details: Servicing provider/facility address and servicing provider NPI/Tax ID
Billing provider: Name of billing provider and billing provider NPI

Documentation Required

Complete form with required clinical and administrative fields

Complete all relevant sections of the form (patient, prescriber, medication, clinical history, prior therapies, labs, signature). You may attach supporting documentation to demonstrate medical necessity. Key suggested attachments: prior therapy records (dates, reasons for discontinuation), relevant laboratory results with dates, documentation of contraindications or adverse reactions, and any peer‑reviewed citations for off‑label or compound use.

Prior therapy records (drug names, dates, reasons for failure/adverse reaction)
Relevant lab results with dates
Documentation of contraindications to alternatives
Peer‑reviewed citations for off‑label or compound use

Prior Authorization

Submit prior authorization request using this form

Use this Massachusetts standardized form to submit prior authorization requests for initial or renewal therapy, step therapy exceptions, quantity exceptions, specialty drug approvals, or other medication determinations. Note: some plans might not accept this form for Medicare or Medicaid requests; plan acceptance may vary.

Billing Rule

Provide billing codes for professionally administered medications

When the request involves professionally administered medications (buy‑and‑bill or facility administration), provide the requested billing information to support claims processing.

Include CPT code and number of visits
Include J code and number of units

Documentation Required

Expedited review attestation

If requesting expedited/urgent review, the prescriber must check the Expedited Review/Urgent Request box on the form and attest that the request meets the definition and criteria for expedited review.

Coding fields on the form

The form includes fields to capture the Primary Diagnosis related to the medication request and associated ICD codes, as well as a section for professionally administered medication billing such as CPT code, number of visits, J code, and number of units. The template references coding systems including ICD-10 for diagnoses and mixed systems for CPT / J codes; note that the code lists are not prepopulated in this template.

ICD codes (patient diagnosis)ICD-10

No codes listed

CPT / J codes (professionally administered medication billing)mixed

No codes listed

Definitions and form background

This Massachusetts standard form is designed to provide a consistent template for payers to collect the clinical and administrative information needed to evaluate medication prior authorization requests. It is intended for use when requesting initial or renewal prior authorization, step therapy exceptions, quantity exceptions, specialty drug approvals, and other medication determinations. Payers and providers should complete all relevant sections and may attach supporting documentation to demonstrate medical necessity.

Definitions (selected)

TermDAW

DefinitionDispense as Written indicator for prescribing brand when generic substitution is not desired.

Revision history

StatusLatest

CURRENT standard form template; no dated revisions recorded in brief.