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The appropriate drug prior authorization (PA) form may be located by using the drug search function (at the top of this page) or by selecting the first letter of the drug to be requested (from the A to Z list displayed above). Once you find the requested drug, click on “PA” next to the drug name and the correct PA form will be highlighted in yellow on the page below.  If you already know which specific PA form you are looking for, you may select it from the following list by clicking on the link below. 

MassHealth providers who can prescribe are encouraged to use the Online PA system to submit electronic drug PAs for review. Prescribers who are not enrolled in MassHealth will need to continue to request prior authorization using the paper form. For more information on how to submit electronic drug prior authorizations via the Online Drug Prior-Authorization (Online PA) application click here.


  • Androgen Therapy [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Anti-Gout Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Anticoagulant and Antiplatelet [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Anticonvulsant [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Antidepressant [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Antidiabetic Agents [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Antiemetics [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Antiretroviral Agents [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Benign Prostatic Hyperplasia (BPH) Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Brand-Name Drug [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Cerebral Stimulant and ADHD Drugs [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Constipation Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Corlanor and Entresto [02/08/16]  ( PDF )  |  TXT
  • Cystic Fibrosis (CFTR) Modulators [02/08/16]  ( PDF )  |  TXT
  • Dermatological Agents (Topical Chemotherapy and Genital Wart Therapy) [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Dermatological Immune Suppressants [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Erythropoietin [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Gastrointestinal Agents - Antidiarrheals and Bowel Preparation Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • General Drug [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Glaucoma Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Gonadotropin Releasing Hormone [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Growth Hormone [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Headache Therapy (Butalbital Combination Agents and Migranal) [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Headache Therapy (Triptan) [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Hepatitis Antiviral Agents [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Hereditary Angioedema Agents [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Hyaluronan Injections [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Hypnotics [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Immune Globulin [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Immunomodulators [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Increlex [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Inhaled Respiratory Agents [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Intranasal Corticosteroids [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Intravenous Antibiotic [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Lipid Lowering Agents [02/12/16]  ( PDF )  |  TXT
  • Modafinil and Nuvigil [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Multiple Sclerosis [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Nonsteroidal Anti-Inflammatory Drugs (NSAID) [02/12/16]  ( PDF )  |  TXT  | Online PA
  • Ophthalmic Anti-Allergy and Anti-Inflammatory Agents [02/12/16]  ( PDF )  |  TXT
  • Opioid Dependence and Reversal Agents [02/12/16]  ( PDF )  |  TXT  | Online PA
  • Opioids/Acetaminophen Analgesic [02/12/16]  ( PDF )  |  TXT  | Online PA
  • Oral Antibiotic [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Oral Respiratory Agents [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Oral/Injectable Antifungal [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Oral/Intranasal Antihistamine Agents [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Osteoporosis Agents [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Otic Antibiotics [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Pediatric Behavioral Health Medication Initiative [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Pediculicides and Scabicides [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Progesterone Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Prostate Cancer Agents [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Proton Pump Inhibitor [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Pulmonary Arterial Hypertension [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Second-Generation (Atypical) Antipsychotic [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Topical Anesthetics [02/08/16]  ( PDF )  |  TXT  | Online PA
  • Topical Antiviral [06/15/15]  ( PDF )  |  TXT  | Online PA
  • Topical Corticosteroids [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Vitamin D Analogues [10/13/15]  ( PDF )  |  TXT  | Online PA
  • Xolair [06/15/15]  ( PDF )  |  TXT  | Online PA