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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

December 2016

Massachusetts Standard Form for Medication Prior Authorization Requests


In August, the Massachusetts Division of Insurance issued a bulletin mandating that health insurance carriers in the state utilize a Massachusetts Standard Form for Medication Prior Authorization Requests. The form was developed by the Massachusetts Collaborative — which comprises representatives from insurance carriers, provider groups, and associations — to increase efficiency and reduce the amount of forms providers have to fill out for different health plans.

Starting immediately, Harvard Pilgrim providers in Massachusetts should use the Massachusetts Standard Form for Medication Prior Authorization Requests to request coverage for most drugs that require prior authorization, as opposed to the medication-specific Medication Request Forms employed previously. As the Massachusetts Standard Form is inherently general, when submitting it to request coverage for a medication, please refer to Harvard Pilgrim’s clinical coverage criteria for that specific medication (found here) and note any supplementary information that may be useful in the “Additional information pertinent to this request” section.

Non-Massachusetts providers

Providers in all other states should continue to use the drug-specific Medication Request Forms, which are located in the “Pharmacy” section of our Provider website, along with the clinical coverage criteria. Completed forms should be faxed to MedImpact Healthcare Systems at 858-790-7100. If you have any questions regarding this process, please contact MedImpact Customer Service at 800-788-2949.

Exceptions to the Massachusetts Standard Form

Please note that Massachusetts standard forms for prior authorization requests for Synagis and for Hepatitis C drugs are currently being developed. Until they have been finalized and approved, Harvard Pilgrim providers in Massachusetts should continue to use the appropriate drug-specific Medication Request Form.

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