Proton Pump Inhibitor Prior Authorization Request 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Enter the last name, first name, MassHealth member ID, gender, date of birth, and place of residence.
3. In the Medication Information section, provide the drug name requested along with its dose, frequency, duration, and diagnosis or indication.
4. Indicate whether the request is for pharmacy or in-office billing. If applicable, detail any previous medications tried for this condition and their outcomes.
5. In Section II, explain the medical necessity of the requested drug and list all current medications along with any relevant diagnostic studies performed.
6. Complete Section III if requesting a non-preferred drug product. Provide justification for prescribing it over preferred options.
7. Finally, fill out Prescriber Information and ensure to sign and date the attestation before submitting your request.

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