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Massachusetts Standard Medication Prior Authorization

Massachusetts insured health plans must accept a standard form for medication prior authorization, step therapy, formulary exception, quantity exception and specialty drug requests. Prescribers meet it whenever a plan or its pharmacy benefit requires approval before covering a drug. Updated with Division of Insurance Bulletin 2024-03 for the 2022 step therapy law, it collects the medication, compound or off-label details, step therapy exception answers, prior therapies and labs.

Who completes it

The prescribing clinician completes the form, including request type, plan, patient, prescriber, medication, clinical and step therapy sections, and the clinician or an authorized representative signs in Section C.

Submitting and payment

How to submit it
Fax or send it to the patient's health plan or prescription plan listed in Section A. Some plans might not accept the form for Medicare or Medicaid requests.

Good to know

  • Section F asks four step therapy exception questions: contraindication or likely harm, expected ineffectiveness, prior failure of the required drug or its class, and stability on the current drug.
  • Compound or off-label requests list the ingredients and include a citation to peer-reviewed literature in Section E.
  • The previous therapies table asks for strength, dosing schedule, dates prescribed and stopped, the adverse reaction or failure, and whether the trial was a sample.
  • A separate block covers professionally administered medications, including buy and bill, with servicing and billing provider details and start and end dates.

Get the official form

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

Massachusetts Standard Form for Medication 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

What changed in the 2024 Massachusetts medication prior authorization form?

Division of Insurance Bulletin 2024-03, issued January 16, 2024, updated the form for the step therapy rules in Chapter 254 of the Acts of 2022. It now has a step therapy exceptions section with four questions, and it replaces the 2016 version issued as Form 1 of Bulletin 2016-08.

Does the Massachusetts standard medication form work for Medicare or MassHealth?

Not always. The form itself warns that some plans might not accept it for Medicare or Medicaid requests. It is the standard request Massachusetts insured plans must accept under M.G.L. c.176O s.25(c), so confirm a public-program plan's own requirements first.