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one: | ☐ Initial Request |  | ☐ Continuation/Renewal Request |\n| Reason for request (check all that apply): | ☐ Prior Authorization, Step Therapy, Formulary Exception\u003Cbr>☐ Quantity Exception\u003Cbr>☐ Specialty Drug\u003Cbr>☐ Other (please specify):   |  |  |\n| Check if Expedited Review/Urgent Request: | ☐ (In checking this box, I attest to the fact that this request meets the definition and criteria for expedited review and is an urgent request.) |  |  |\n|  |  |  |  |\n| A. Destination—Where this form is being submitted to; payers making this form available on their websites may prepopulate section A |  |  |  |\n| Health Plan or Prescription Plan Name: |  |  |  |\n| Health Plan Phone: |  | Fax: |  |\n\n\n| B. Patient Information |  |  |\n| --- | --- | --- |\n| Patient Name: | DOB: | Gender: ☐ Male ☐ Female ☐ Unknown |\n| Member ID \\#: |  |  |\n\n| C. Prescriber Information |  |\n| --- | --- |\n| Prescribing Clinician: | Phone \\#: |\n| Specialty: | Secure Fax \\#: |\n| NPI \\#: | DEA/xDEA: |\n| Prescriber Point of Contact Name (POC) (if different than provider): |  |\n| POC Phone \\#: | POC Secure Fax \\#: |\n| POC Email (not required): |  |\n| Prescribing Clinician or Authorized Representative Signature: |  |\n| Date: |  |\n\n\n| D. Medication Information |  |\n| --- | --- |\n| Medication Being Requested: |  |\n| Strength: | Quantity: |\n| Dosing Schedule: | Length of Therapy: |\n| Date Therapy Initiated: |  |\n| Is the patient currently being treated with the drug requested? ☐ Yes ☐ No If yes, date started: |  |\n| Dispense as Written (DAW) Specified? ☐ Yes ☐ No |  |\n| Rationale for DAW: |  |\n\n\n| E. Compound and Off Label Use |  |\n| --- | --- |\n| Is Medication a Compound? ☐ Yes ☐ No |  |\n| If Medication Is a Compound, List Ingredients: |  |\n| For Compound or Off Label Use, include citation to peer reviewed literature: |  |\n\n 1 (continued on next page) Massachusetts Collaborative—Massachusetts Standard Form for Medication Prior Authorization Requests May 2016 (version 1. 0)  \n\n| F. Patient Clinical Information |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| *Please refer to plan-specific criteria for details related to required information. |  |  |  |  |  |  |  |\n| Primary Diagnosis Related to Medication Request: |  |  |  |  |  |  |  |\n| ICD Codes: |  |  |  |  |  |  |  |\n| Pertinent Comorbidities: |  |  |  |  |  |  |  |\n| If Relevant to This Request: |  |  |  |  |  |  |  |\n| Drug Allergies: |  |  |  |  |  |  |  |\n| Height: |  |  |  | Weight: |  |  |  |\n| Pertinent Concurrent Medications: |  |  |  |  |  |  |  |\n| Opioid Management Tools in Place: ☐ Risk assessment ☐ Treatment Plan ☐ Informed Consent ☐ Pain Contract ☐ Pharmacy/Prescriber Restriction |  |  |  |  |  |  |  |\n| Previous Therapies Tried/Failed: |  |  |  |  |  |  |  |\n| Previous Therapies |  |  |  |  |  |  |  |\n| Drug Name | Strength | Dosing\u003Cbr>Schedule | Date\u003Cbr>Prescribed |  | Date\u003Cbr>Stopped | Description of Adverse Reaction or Failure | Check if\u003Cbr>Sample |\n|  |  |  |  |  |  |  | ☐ |\n|  |  |  |  |  |  |  | ☐ |\n|  |  |  |  |  |  |  | ☐ |\n|  |  |  |  |  |  |  | ☐ |\n|  |  |  |  |  |  |  | ☐ |\n| Are there contraindications to alternative therapies? ☐ Yes ☐ No |  |  |  |  |  |  |  |\n| If yes, please list details: |  |  |  |  |  |  |  |\n| Were nonpharmacologic therapies tried? ☐ Yes ☐ No |  |  |  |  |  |  |  |\n| If yes, provide details: |  |  |  |  |  |  |  |\n| Relevant Lab Values |  |  |  |  |  |  |  |\n| Lab Name and Lab Value | Date Performed |  | Lab Name and Lab Value |  |  |  | Date Performed |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| If renewal, has the patient shown improvement in related condition while on therapy? ☐ Yes ☐ No ☐ N/A |  |  |  |  |  |  |  |\n| If yes, please describe: |  |  |  |  |  |  |  |\n| Additional","cbCainWGFT7ogwms","https://ap.wps.com/l/cbCainWGFT7ogwms","pdf",102048,"English","# Where this form is being submitted to\n## Patient information\n## Prescriber information\n## Medication information\n## Compound and off-label use\n## Patient clinical information","[{\"question\":\"What information is required about the plan and submission destination?\",\"answer\":\"The form requests the health plan or prescription plan name plus contact details such as phone and fax for where the request is submitted.\"},{\"question\":\"What medication details must be completed for a prior authorization request?\",\"answer\":\"It requires the medication name, strength, quantity, dosing schedule, therapy length, date therapy was initiated, whether the patient is currently treated with the drug, and DAW selection with rationale.\"},{\"question\":\"How does the form collect supporting clinical information?\",\"answer\":\"It captures primary diagnosis and ICD codes, pertinent comorbidities, drug allergies, height and weight, concurrent medications, opioid management tools, prior therapies tried and outcomes, contraindications and alternative or nonpharmacologic therapy attempts, relevant lab values, and renewal improvement when applicable.\"}]","MA-Express Scripts Prior Authorization Request Form - Massachusetts Standard Form for Medication Prior Authorization Requests | PDF",1789620640]