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Massachusetts Chemotherapy & Supportive Care PA Form

Massachusetts insured health plans use this standard form for prior authorization of anti-cancer regimens and supportive care drugs such as antiemetics, bone-strengthening agents and ESAs. Oncologists and other prescribers meet it when starting, re-authorizing or retrospectively requesting treatment for a plan member. Issued with Division of Insurance Bulletin 2024-03, it captures staging, ECOG score, drug codes and billing method, and plans may accept their portal instead.

Who completes it

The ordering or treating oncology clinician's office completes all five sections: member and tumor details, the anti-cancer regimen, supportive care drugs, provider and place of treatment, and any step therapy exception. The patient completes nothing.

Submitting and payment

How to submit it
Fax the form to the patient's health plan with progress notes, chemotherapy orders, labs, pathology and imaging results, or enter the request in the plan's portal, which the form allows in its place. Mark Standard or Expedited at the top.

Good to know

  • For each anti-cancer drug, give the J code, route, dose, schedule, cycles, buy-and-bill or pharmacy billing, FDA approval for the diagnosis, and willingness to dose-round single-use vials.
  • Bone-strengthening agents need an indication (osteoporosis, bone metastases, hypercalcemia, adjuvant breast cancer); ESAs need CKD, chemotherapy-induced anemia, MDS or anemia of chronic disease.
  • Section IV asks about prior therapies, biomarker or genetic testing, and, for out-of-network requests, whether the provider is the only one available within a reasonable distance.
  • This 2024 form replaced the 2022 Oncology Prior Authorization Form issued with Bulletin 2022-07.

Get the official form

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

Massachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I submit the Massachusetts chemotherapy PA through a health plan portal?

Yes. The form states that providers may use the health plan's portal in place of the paper form. When the paper form is used, it should go with the required attachments: progress notes, chemotherapy orders, labs, pathology and imaging results.

What replaced the Massachusetts Oncology Prior Authorization Form?

The Massachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests, issued with Division of Insurance Bulletin 2024-03, replaced the 2022 Oncology Prior Authorization Form from Bulletin 2022-07. The current form has five sections, including supportive care drugs and step therapy exceptions.