CurrentMass General Brigham Health PlanPolicy N/A

MASSACHUSETTS STANDARD FORM FOR MEDICATION PRIOR AUTHORIZATION REQUESTS

A standardized form for providers to request medication prior authorization, step therapy exceptions, quantity exceptions, specialty drug requests, and continuations for Massachusetts health plans; includes patient, prescriber, medication, clinical, step-therapy exception, and billing fields. Some plans may not accept the form for Medicare or Medicaid requests.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMASSACHUSETTS STANDARD FORM FOR MEDICATION PRIOR AUTHORIZATION REQUESTS

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete sections A–G as appropriate, including patient, prescriber, medication, clinical rationale, previous therapies, labs, and step therapy exception details; attach additional data relevant to medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported.

MultipleSupported Request Types

A–GForm Sections

Policy summary and scope

Purpose: This is a standardized Massachusetts prior authorization (PA) form for participating health plans to collect required information to support medication authorization decisions, including provider-administered/billing details.

Intended use cases: Use this form to request Prior Authorization, Step Therapy exceptions, Formulary Exception, Quantity Exception, Specialty Drug requests, and Continuation/Renewal requests; it also supports expedited/urgent attestations and documentation for DAW and clinical rationale.

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Form metadata and stats

PayerMass General Brigham Health Plan

Policy TitleMASSACHUSETTS STANDARD FORM FOR MEDICATION PRIOR AUTHORIZATION REQUESTS

Policy NumberN/A

Effective Date

Scope SummaryA standardized form for providers to request medication prior authorization, step therapy exceptions, quantity exceptions, specialty drug requests, and continuations for Massachusetts health plans; includes patient, prescriber, medication, clinical, step-therapy exception, and billing fields. Some plans may not accept the form for Medicare or Medicaid requests.

Supported Request TypesForm collects multiple request types (Initial, Continuation/Renewal, Prior Authorization, Step Therapy, Formulary Exception, Quantity Exception, Specialty Drug, Other)

Form SectionsSections A–G

Which requests and clinical data the form collects

Form Completion / Request Types

This form is used when a provider is requesting any of the following; check applicable boxes:

Request Types

Initial Request
Continuation/Renewal Request
Prior Authorization
Step Therapy
Formulary Exception
Quantity Exception
Specialty Drug
Other (Please specify)

Expedited Review / Urgent Request Attestation

Provider may check if the request meets the carrier's definition of expedited/urgent:

Expedited Review Attestation: Check box attesting request meets definition and criteria for expedited review and is urgent as defined by the carrier

In checking this box, attest to the fact that this request meets the definition and criteria for expedited review and is an urgent request as defined by the carrier.

Step Therapy Exception Criteria (Section F)

Complete applicable sections to request an exception to step therapy:

Step Therapy Exception Criteria

Contraindication or Harm: Alternative required under step therapy is contraindicated, will cause an adverse reaction, or physical/mental harm
If yes, provide details of contraindication/adverse reaction/harm
Expected Ineffectiveness: Alternative required under step therapy is expected to be ineffective based on known clinical characteristics
If yes, provide rationale
Prior Trial History: Member previously tried the alternative or another drug in same class/mechanism and it was discontinued due to lack of efficacy, diminished effect, or adverse event
If yes, provide drug name, dates/duration, details and indicate adverse reaction or inadequate response

Clinical Information / Documentation Requirements

Providers must supply clinical information relevant to the request:

Clinical Documentation Requirements

Primary Diagnosis and Codes: Primary diagnosis related to medication request and ICD codes
Comorbidities and Concurrent Medications: Pertinent comorbidities and concurrent medications
Drug Allergies: Drug allergies
Height and Weight: Height and weight (when relevant)

Compound and Off-Label Use

Requirements when requesting compound or off-label medications:

Compound and Off-Label Use Requirements

Compound Ingredients: Indicate if medication is a compound and list ingredients
Peer-Reviewed Citation: Include citation to peer-reviewed literature for compound or off-label use

Professionally Administered / Buy-and-Bill Medications

Additional fields required for provider-administered medications:

Professionally Administered Medication Fields

Start Date: Start date
Servicing Prescriber/Facility and NPI/Tax ID: Servicing prescriber/facility name and address; servicing provider NPI/Tax ID
Billing Provider and NPI: Name of billing provider and billing provider NPI
Reauthorization Indicator: Indicate if this is a reauthorization request

Billing and diagnostic codes collected on the form

Diagnostic / Billing Codes Collected on Formmixed

CPT	Form requests provider to list CPT code for professionally administered medications (CPT Code and # of Visits)
J-code	Form requests provider to list J-code and number of units for administered medications (J Code and # of Units)
ICD-10	Form requests provider to list ICD codes for primary diagnosis related to medication request (ICD Codes)

Required actions and documentation for providers

Documentation Required

Complete all applicable form sections

Providers must complete Sections A–G of the form. This includes: patient identification and demographics; prescriber information; medication details (name, strength, dosing, quantity, length of therapy, date therapy initiated, DAW rationale); clinical rationale and indication; previous therapies/trial history and outcomes; relevant labs and comorbidities; and step therapy exception details when applicable. Attach any additional data relevant to medical necessity (clinical notes, chart excerpts, prior authorization letters, imaging, consult reports).

Section A: Destination/Health Plan contact information (if not prepopulated)
Section B: Patient name, DOB, member ID, sex assigned at birth, current gender
Section C: Prescribing clinician name, specialty, phone, secure fax, NPI, DEA, prescriber POC and signature/date
Medication section: medication requested, strength, quantity, dosing schedule, length of therapy, date therapy initiated, current treatment status, DAW and rationale
Section D/E: Compound/off-label details and supporting literature citations when applicable
Section F: Step therapy exception documentation (see checklist below)
Section G: Clinical information — primary diagnosis, ICD codes, comorbidities, allergies, height/weight, concurrent meds, previous therapies tried/failed, pertinent lab values, risk assessment and informed consent details
Attach supporting documentation: progress notes, prior trial documentation (dates, dosages, outcomes), lab results, and specialty consult notes

Prior Authorization

Use form for PA and exceptions

Use this form to request: prior authorization, step therapy exception, formulary or quantity exception, specialty drug requests, and renewals/continuation. For expedited/urgent review, check the Expedited Review/Urgent Request box only when the request meets the carrier’s definition and criteria for expedited review; checking the box attests that the situation satisfies those urgent criteria.

Select the appropriate reason for request: Prior Authorization, Step Therapy Exception, Formulary Exception, Quantity Exception, Specialty Drug, Renewal
Use the form for initial and continuation requests
Only use the expedited review checkbox when the clinical situation meets the carrier’s urgent criteria and you attest to that fact

Billing Rule

Reporting of administration and billing codes

For professionally administered medications or buy-and-bill requests, provide complete billing and administration details to avoid processing delays.

Servicing provider/facility name and address
Servicing provider NPI and tax ID
Name of billing provider and billing provider NPI
Start date of administration and indicate if this is a reauthorization
CPT code(s) and number of visits
HCPCS/J-code(s) and number of units
Indicate if sample was used (where applicable)

Documentation Required

Step therapy exception evidence

When requesting a step therapy exception, submit clear evidence that the alternative required by protocol is contraindicated, ineffective, or would cause harm. Provide prior trial history with dates and outcomes or other clinical rationale supporting the exception.

Document contraindications or adverse reactions to the required alternative(s) with details and dates
Provide prior trial history for alternatives (drug name, dates/duration, dosing, reason for discontinuation: inadequate response, adverse reaction, other)
If alternatives are expected to be ineffective, explain why given the member’s clinical characteristics
If member is stable on the requested medication, document stability and why switching is likely to cause harm
Include lab support or imaging when relevant and copies of clinic notes or consultation reports supporting claims

Key terms and form-specific definitions

Definitions

Expedited Review/Urgent RequestProvider attestation that the request meets the definition and criteria for expedited review; requires checking the expedited box to attest the request is urgent as defined by the carrier.

DAW (Dispense As Written)Indicate whether DAW is specified (Yes/No) and provide rationale for DAW on the form.

Background summary: The form is intended for participating health plans to collect the information needed to make medication authorization decisions and to document step therapy exceptions and billing/administration details for provider-administered medications. Note: Some plans might not accept this form for Medicare or Medicaid requests.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMASSACHUSETTS STANDARD FORM FOR MEDICATION PRIOR AUTHORIZATION REQUESTS

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Member Stable on Therapy: Member is stable on the requested medication and switching is likely to cause adverse reaction or harm

If yes, provide details

Previous Therapies Tried:

Previous therapies tried/failed with dates, dosing, and reason for discontinuation (adverse reaction or failure)

Include details: drug name, strength, dosing, dates, description of adverse reaction or failure

Relevant Labs: Relevant lab values with dates

Renewals Documentation: For renewals, documentation of improvement while on therapy if applicable

If renewal, indicate whether patient has shown improvement and describe

CPT Code and Visits: Provide CPT code and # of visits

J-code and Units: Provide J-code and # of units

OpenPayer

MASSACHUSETTS STANDARD FORM FOR MEDICATION PRIOR AUTHORIZATION REQUESTS

Policy summary and scope

Which requests and clinical data the form collects

Billing and diagnostic codes collected on the form

Required actions and documentation for providers

Key terms and form-specific definitions

Document revisions