New in 2024: Optum Rx and Specialty Fusion
Check back frequently for the latest updates.
Our Pharmacy Benefit Manager (PBM)
will become Optum Rx on January 1, 2024
As health care changes at a rapid pace, Mass General Brigham Health Plan continues to innovate and build on our total cost of care model. To create lasting value for our clients and members we serve now and, in the future, we are changing our pharmacy vendor to Optum Rx. Making pharmacy care more affordable, accessible, supportive, and personal for our members is a shared goal with Optum Rx.
FAQs about Optum Rx
Optum Rx met critical financial and operational performance indicators that will drive the most value for our members.
Optum Rx will be performing review of prior authorization for non-specialty pharmacy benefit medications.
Specialty Fusion will review medical specialty and self-administered specialty medications. More information below.
Optum Rx takes effect on January 1, 2024.
All existing authorizations will be transferred from the current pharmacy benefit manager (PBM) to Optum Rx.
For non-specialty authorizations please submit to Optum Rx. For specialty authorizations please see Specialty Fusion FAQs section below.
For more information, please visit https://professionals.optumrx.com/
Existing mail order prescriptions with refills will be transferred to Optum Home Delivery.
The Commercial and Medicaid lines of business will be transitioning to Optum Rx. Excluding Medicare Advantage and ASO with pharmacy carve-outs.
Members can visit https://massgeneralbrighamhealthplan.org/pharmacy-2024 for information regarding this change.
Yes, members will be notified by Optum Rx and Mass General Brigham Health Plan.
Yes, members will be receiving new ID cards.
Optum Rx offers an extensive national Pharmacy network including most major chain pharmacies, grocery store pharmacies, and many independent pharmacies.
FAQs about Specialty Fusion
Specialty Fusion is a system that integrates medical and pharmacy benefits into a single platform, so you can streamline your process while gaining full visibility to specialty trends. Connect patients and providers with the right treatments at the optimal cost—faster than ever. Optum Rx is the pharmacy benefit manager that will be administering the pharmacy benefit and performing prior authorization review for non-specialty pharmacy benefit medications.
The Commercial and Medicaid lines of business will be transitioning to Optum Rx. Excluding Medicare Advantage.
All existing authorizations will be transferred to Specialty Fusion.
Electronic requests can be submitted to Specialty Fusion through the Mass General Brigham Health Plan Provider Portal beginning January 1, 2024. Select Specialty Fusion link to complete authorization.
Starting January 1, 2024, please see https://www.massgeneralbrighamhealthplan.org/providers/pharmacy-guidelines for information on how you should submit requests. Changes may occur throughout the year. *
PBM Change Impacts
Commercial/Exchange and MassHealth
| Before 01/01/2024 | Starting 01/01/2024 | |
| Pharmacy Benefit Manager | CVS Caremark | Optum Rx |
| Specialty Pharmacy | CVS Specialty | Specialty Fusion |
| Mail Order Services | CVS Caremark Mail Service | Optum Rx Home Delivery |
| Formulary Management | Mass General Brigham Health Plan | Mass General Brigham Health Plan |
| Non-Specialty Prior Authorization Review* | CVS Caremark | Optum Rx Phone: 800-711-4555 Fax: 844-403-1029 |
| Non-Formulary Prior Authorization Review (Specialty & Non-Specialty) | CVS Caremark | Optum Rx Phone: 800-711-4555 Fax: 844-403-1029 |
| Specialty Prior Authorization Review (Medical) | NovoLogix | Specialty Fusion Phone: 877-519-1908 Fax: 855-540-3693 |
| Specialty Prior Authorization Review (Pharmacy)* | CVS Caremark | Specialty Fusion Phone: 877-519-1908 Fax: 855-540-3693 |
| Appeals and Grievances | Mass General Brigham Health Plan | Mass General Brigham Health Plan |
If you have any technical problems or comments, please contact Specialty Fusion at: optum_specialty_fusion@optum.com
In the coming weeks, we will partner with Optum to present web orientation sessions designed to assist you and your staff with the new prior authorization portal. You are invited to attend the session best suited to your specialty. We will also record and post the sessions on this page.
During these sessions, we will discuss in detail the prior authorization requirements for Mass General Brigham Health Plan members and how to navigate the Optum platform. We encourage you to attend to ensure you understand the new prior authorization process.
Registration information coming soon! Dates and times for the two sessions are below.
For more information, please visit https://info.optum.com/specialty-fusion
Provider trainings for Specialty Fusion
| Session 1: December 12, 2023 | 10:00 AM EST | 11:00 AM EST | Register here |
| Session 2: December 14, 2023 | 4:00 PM EST | 5:00 PM EST | Register here |
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