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Prior Authorization Forms for Pharmacy Services

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The appropriate drug prior authorization (PA) form may be located by using the drug search function (at the top of this page) or by selecting the first letter of the drug to be requested (from the A to Z list displayed above). Once you find the requested drug, click on “PA” next to the drug name and the correct PA form(s) will be highlighted in yellow on the page below.  If you already know which specific PA form you are looking for, you may select it from the following list by clicking on the link below. In general, for indications not designated on the PA form (including non-FDA-approved indications), please use the “Other” indication check box, and attach a letter documenting additional information as applicable. 

Please note, information on MassHealth Managed Care Organization (MCO) medical billing, one-time cell and gene therapies, and specialty pharmacy is available at: MassHealth Accountable Care Partnership Plans and Managed Care Organizations Pharmacy Information.

Online PA

Online PA submission option is available for the below MassHealth Managed Care Organization (MCO) plans. Please note, one-time cell and gene therapies are part of the ACPP and MCO unified pharmacy policy. PA requests for one-time cell and gene therapies for members with ACPP and MCO plans are reviewed by the MassHealth Drug Utilization Review (DUR) Program and should be submitted to the MassHealth DUR Program using the One-Time Cell and Gene Therapies PA Request form.

  • Androgen Therapy  [ 01/06/25 ]   | 

  • Anti-Amyloid Monoclonal Antibodies  [ 01/06/25 ]   | 

  • Anti-Obesity Agents  [ 04/15/25 ]   | 

  • Anticoagulant and Antiplatelet  [ 01/06/25 ]   | 

  • Anticonvulsant  [ 01/06/25 ]   | 

  • Antidepressant  [ 04/01/25 ]   | 

  • Antidiabetic Agents  [ 04/15/25 ]   | 

  • Antiemetics  [ 04/01/25 ]   | 

  • Antihistamine Agents  [ 01/06/25 ]   | 

  • Antipsychotic  [ 04/01/25 ]   | 

  • Antiretroviral Agents  [ 02/18/25 ]   | 

  • Asthma/Allergy Monoclonal Antibodies  [ 04/01/25 ]   | 

  • Benign Prostatic Hyperplasia (BPH) Agents  [ 01/06/25 ]   | 

  • Benzodiazepines and Other Antianxiety Agents  [ 01/06/25 ]   | 

  • Beta Thalassemia, Myelodysplastic Syndrome, and Sickle Cell Disease Agents  [ 04/01/25 ]   | 

  • Brand-Name and Non-Preferred Generic Drug  [ 01/06/25 ]   | 

  • Breast Cancer Agents  [ 04/01/25 ]   | 

  • Cerebral Stimulant and ADHD Drugs  [ 01/06/25 ]   | 

  • Constipation Agents  [ 02/18/25 ]   | 

  • Cystic Fibrosis Agents  [ 04/01/25 ]   | 

  • Dermatological Agents (Topical Chemotherapy and Genital Wart Therapy)  [ 01/06/25 ]   | 

  • Diabetes Medical Supplies  [ 02/18/25 ]   | 

  • Erythropoiesis-Stimulating Agents  [ 01/06/25 ]   | 

  • Gastrointestinal Agents - Antidiarrheals and Bowel Preparation Agents  [ 01/06/25 ]   | 

  • General Drug  [ 01/06/25 ]   | 

  • Glaucoma Agents  [ 01/06/25 ]   | 

  • Gonadotropin-Releasing Hormone  [ 01/06/25 ]   | 

  • Gout Agents  [ 01/06/25 ]   | 

  • Growth Hormone and Increlex  [ 01/06/25 ]   | 

  • Headache Therapy (Butalbital Combination Agents)  [ 01/06/25 ]   | 

  • Headache Therapy (Calcitonin Gene-Related Peptide [CGRP] Inhibitors)  [ 01/06/25 ]   | 

  • Headache Therapy (Ergot Alkaloids and Serotonin Receptor Agents)  [ 01/06/25 ]   | 

  • Heart Failure Agents  [ 04/01/25 ]   | 

  • Hepatitis Antiviral Agents  [ 01/06/25 ]   | 

  • Hereditary Angioedema Agents  [ 04/01/25 ]   | 

  • Hyaluronan Injections  [ 01/06/25 ]   | 

  • Hypnotic Agents  [ 01/06/25 ]   | 

  • Imcivree  [ 01/06/25 ]   | 

  • Immune Globulin  [ 01/06/25 ]   | 

  • Inhaled Respiratory Agents  [ 01/06/25 ]   | 

  • Injectable Antibiotic  [ 01/06/25 ]   | 

  • Intranasal Corticosteroids  [ 01/06/25 ]   | 

  • Lipid-Lowering Agents  [ 02/18/25 ]   | 

  • Lung Cancer Agents  [ 04/01/25 ]   | 

  • Multiple Myeloma Agents  [ 01/06/25 ]   | 

  • Multiple Sclerosis Agents  [ 01/06/25 ]   | 

  • Narcolepsy and Miscellaneous Sleep Disorder Therapy Agents  [ 01/06/25 ]   | 

  • Neuromuscular Agents  [ 04/01/25 ]   | 

  • Nonsteroidal Anti-Inflammatory Drugs (NSAID)  [ 01/06/25 ]   | 

  • Oncology Agents  [ 01/06/25 ]   | 

  • One-Time Cell and Gene Therapies  [ 04/01/25 ]   | 

  • Ophthalmic Anti-Allergy and Anti-Inflammatory Agents  [ 01/06/25 ]   | 

  • Opioid Dependence and Reversal Agents  [ 01/06/25 ]   | 

  • Opioids/Acetaminophen Analgesic  [ 04/01/25 ]   | 

  • Oral Antibiotics and Anti-Infectives  [ 01/06/25 ]   | 

  • Oral Respiratory Agents  [ 01/06/25 ]   | 

  • Oral/Injectable Antifungal Agents  [ 02/18/25 ]   | 

  • Osteoporosis Agents and Calcium Regulators  [ 04/01/25 ]   | 

  • Otic Agents  [ 01/06/25 ]   | 

  • Pediatric Behavioral Health Medication Initiative  [ 02/18/25 ]   | 

  • Pediculicides and Scabicides  [ 01/06/25 ]   | 

  • Progesterone Agents  [ 01/06/25 ]   | 

  • Prostate Cancer Agents  [ 01/06/25 ]   | 

  • Proton Pump Inhibitor  [ 04/01/25 ]   | 

  • Pulmonary Hypertension  [ 01/06/25 ]   | 

  • Rezdiffra  [ 01/06/25 ]   | 

  • T-cell Immunotherapies  [ 04/01/25 ]   | 

  • Targeted Immunomodulators  [ 04/01/25 ]   | 

  • Thrombocytopenic Agents  [ 01/06/25 ]   | 

  • Topical Anesthetics  [ 01/06/25 ]   | 

  • Topical Corticosteroids  [ 04/01/25 ]   | 

  • Topical Vitamin D Analogues  [ 01/06/25 ]   | 

  • Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors  [ 01/06/25 ]   | 

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