90 day waiver form 2026

1. Click ‘Get Form’ to open the 90-day waiver form in the editor.
2. Begin by filling out the Pharmacy Information section. Enter the date, pharmacy name, provider number, fax number, and location code as required.
3. Next, complete the MassHealth Member Information section. Input the member's last name, first name, date of birth (in mmddyyyy format), gender, address, city, state, ZIP code, and member ID.
4. Proceed to the Claim Information section. For each prescription listed, provide details such as manufacturer, item, package size (Pkg.), drug name, prescriber’s NPI (National Provider Identifier), date written, date filled, and prescription number.
5. Indicate the quantity and days’ supply for each prescription along with usual charge and any other paid amount. Ensure all fields are completed accurately.
6. In the Explanation box at the bottom of the form, select one of the reasons for requesting a 90-day waiver and attach any necessary documentation if applicable.
7. Once all sections are filled out correctly, review your entries for accuracy before submitting. Finally, fax the completed form to Xerox State Healthcare at 1-866-556-9315.

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