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Massachusetts standard form for medication prior authorization requests 2026
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How to use or fill out Massachusetts Standard Form for Medication Prior Authorization Requests
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting whether this is an Initial Request or a Continuation/Renewal Request. Check the appropriate box.
- Indicate the reason for the request by checking all applicable options, such as Prior Authorization or Specialty Drug.
- If this is an urgent request, check the box for Expedited Review and ensure you meet the criteria.
- Fill in Section A with the Health Plan or Prescription Plan Name and contact details.
- In Section B, provide Patient Information including name, date of birth, gender, and member ID number.
- Complete Section C with Prescriber Information including clinician's name, phone number, specialty, and NPI number.
- In Section D, detail Medication Information such as medication name, strength, quantity requested, and dosing schedule.
- For Sections E and F, provide information on compound medications and patient clinical details as required.
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What is a prior authorization form for prescriptions?
It refers to the number of days you may need to wait between refills of 30-day prescriptions that are considered controlled substances. If you have a medication that follows the 28-day rule on a 30-day supply, it means you can get a refill no earlier than 2 days before the 30 days are up.
Can I fill out my own prior authorization form?
Prior authorization requests should be faxed to the Precertification Operations Department at 888-415-9055 (Tufts Health Together, Tufts Health Direct), 857-304-6304 (Tufts Health One Care) or 857-304-6404 (Tufts Health RITogether).
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massachusetts standard form for medication prior authorization requests
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