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MassHealth General Drug Prior Authorization Request

MassHealth uses the General Drug Prior Authorization Request for drugs on the MassHealth Drug List that need prior authorization but have no drug- or class-specific form. Prescribers meet it for non-preferred drugs, compounds and step therapy exceptions for members in fee-for-service, the PCC Plan, Primary Care ACOs and the managed care plans. Requests are reviewed for medical necessity, and MassHealth notifies both the prescriber and the member of the decision.

Who completes it

The prescriber, or someone authorized to act for them, completes the member and medication details, Sections I to V as they apply, and the prescriber information, then signs the attestation.

Submitting and payment

How to submit it
Fax or submit it to the member's plan using page 1: the MassHealth Drug Utilization Review Program for fee-for-service, PCC Plan and Primary Care ACO members, or the online PA portals and fax lines of Fallon Health, Health New England, Mass General Brigham Health Plan, Tufts Health Plan or WellSense.
Who pays
Approval rests on medical necessity only, and payment is still subject to MassHealth's general conditions, including the member's current eligibility, other insurance and program restrictions.

Good to know

  • Check the MassHealth Drug List first: many drugs have their own PA form, and medications under the Pediatric Behavioral Health Medication Initiative use a separate form.
  • Section III explains why a non-preferred product is needed over a preferred one, Section IV covers compounds, and Section V documents step therapy exceptions.
  • For professionally administered drugs, complete the servicing provider, billing provider, CPT and J code, visits and units fields on the last page.
  • The current revision is PA-2 (Rev. 01/26). Give a fax number in the prescriber section, since it is used for the PA response notification.

Get the official form

Download the current version from the source each time; forms change without notice.

General Drug Prior Authorization Request (MassHealth Drug List)

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Which MassHealth members does the General Drug PA form cover?

MassHealth's MCO and Accountable Care Partnership Plans follow the unified MassHealth Drug List. Page 1 routes the form: fee-for-service, PCC Plan, Primary Care ACO and Children's Medical Security Plan members go to the Drug Utilization Review Program, and plan members go to their plan's pharmacy contacts.

Can the MassHealth drug PA form be signed electronically?

Yes, with DocuSign or Adobe Sign, and the signer may upload a picture of their wet signature; a typed signature is not acceptable. It can also be signed by hand and scanned. The signer certifies, under the pains and penalties of perjury, that the medical necessity information under 130 CMR 450.204 is true.