Proton Pump Inhibitor Prior Authorization Request 2025

1. Click ‘Get Form’ to open the Proton Pump Inhibitor Prior Authorization Request in the editor.
2. Begin by filling out the Member Information section. Enter the member's last name, first name, MassHealth member ID number, gender, and date of birth. Specify the member’s place of residence as either home or nursing facility.
3. In the Medication Information section, provide the requested drug name, dosage, frequency, duration, and diagnosis. If known, include the Drug NDC or service code.
4. Indicate whether the request is for pharmacy or in-office billing. Answer if the member has tried other medications for this condition and provide details if applicable.
5. Complete Section II by explaining the medical necessity of the requested drug and listing all current medications along with any relevant diagnostic studies performed.
6. If applicable, fill out Section III for non-preferred drug products by providing justification for prescribing them over preferred options.
7. Finally, complete the Prescriber Information section with required details and ensure to sign and date where indicated.

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