.TitlePage { color: #616262; font-family: 'MuseoSans'; font-size:32px; } .TDList { padding-left:45px; padding-top:10px; padding-bottom:10px; font-size:22px; }

Forms

Please click on the file that you need and it will open in PDF format so you can print it. If you need acrobat reader please click here to download it. 

Providers

Pharmacy

Review process for requests to bypass Step Therapy, Quantity Limit and Brand restrictions. Our providers may initiate the review request by completing our Medication Request Form (located in the Drug Formulary) or by contacting member services at (800) 310-2835 and having the form faxed directly to the office.

To ensure that you are submitting the correct form, please search the requested drug on our online Drug Formulary to obtain the appropriate prior-authorization form.

Review request for newly approved drugs and quantity limitations. If a physician requests an FDA approved medication for a non-FDA approved disease state/condition, or dosing schedule, you must submit at least 3 peer-reviewed journal articles or abstracts; a national or published Clinical Guideline; and/or published information regarding current standard of care.

Please click on the form that you need and it will open in PDF format so you can print it. 

Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests

Massachusetts Standard Form for Medication Prior Authorization Requests

Massachusetts Standard Form for Synagis® Prior Authorization Requests

Medication Request Form for Prior Authorization

Out of Network Prescription Reimbursement Form

Prescription Drug Program Mail Service Form