MassHealth
Commonwealth of Massachusetts
Executive Offce of Health and Human Services
www.mass.gov/masshealth
Pharmacy 90-Day Waiver Form

Use this form to request a 90-day waiver for one of the reasons indicated in the Explanation box below.
All felds must be completed to process the request.

Pharmacy information
(Required to receive approval notifcation)	
Date
Pharmacy name
Provider number
Fax number
Location code
			
MassHealth member information
Last name
First name
Date of birth (mmddyyyy)
Gender f   m
Member ID
Address
City
State
ZIP
				
Claim Information
1 Manufacturer				Item			Pkg.	
  Prescriber’s NPI			Date written		Date filled
  Drug name				Quantity		Days’ supply
  Prescription no.	Usual charge	Other pd. amount	Prior auth. no.


2 Manufacturer				Item			Pkg.	
  Prescriber’s NPI			Date written		Date filled
  Drug name				Quantity		Days’ supply
  Prescription no.	Usual charge	Other pd. amount	Prior auth. no.


3 Manufacturer				Item			Pkg.	
  Prescriber’s NPI			Date written		Date filled
  Drug name				Quantity		Days’ supply
  Prescription no.	Usual charge	Other pd. amount	Prior auth. no.


4 Manufacturer				Item			Pkg.	
  Prescriber’s NPI			Date written		Date filled
  Drug name				Quantity		Days’ supply
  Prescription no.	Usual charge	Other pd. amount	Prior auth. no.



Explanation: Please indicate the reason for the 90-day waiver below.
	Rebilling a previously denied timely filed claim (attach remittance advice)
	Retroactive member enrollment (attach proof)
	Retroactive provider enrollment (attach proof)


Please fax the completed form to Xerox State Healthcare at 1-866-556-9315.

Note: Submit claims that are older than 12 months (18 months for third party liability 
claims) directly to: MassHealth Final Deadline Appeals, 100 Hancock Street, 
Quincy, MA 02171 (Tel.: 617-847-3115).

PHM-2 (Rev. 04/13)