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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 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 following MassHealth Managed Care Organization (MCO) plans: