New in 2026: Prime Therapeutics
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Prime Therapeutics: Specialty drug management
Mass General Brigham Health Plan is committed to providing our members with access to high-quality health care that is consistent with evidence-based, nationally recognized clinical criteria and guidelines. Therefore, we will be implementing a change in the way we manage certain specialty drugs that fall under the medical benefit. This new program will be administered by the Medical Pharmacy Solutions team at Prime Therapeutics (Prime).
Beginning December 22, 2025, providers should begin contacting Prime to obtain prior authorizations via web, fax, or phone or the in-scope drugs for our members with dates of service on or after January 1, 2026. Please note the drugs considered in-scope vary by member plan.
FAQs about Prime
The program will apply to the following plans*:
- Mass General Brigham ACO (MassHealth)
- Mass General Brigham Commercial
- Mass General Brigham Commercial (QHP)
- Mass General Brigham Advantage Secure (HMO-POS)
- Mass General Brigham Advantage Signature (PPO)
- Mass General Brigham Advantage Premier (PPO)
- Mass General Brigham Advantage (PPO)
- Mass General Brigham Advantage Group (PPO)
- Mass General Brigham SCO (HMO D-SNP)
- Mass General Brigham One Care (HMO D-SNP)
*The Medicare Part D Group PDP is not included in this program as this plan does not have Part B medical drug coverage.
Although the effective date of this program is January 1, 2026, providers can begin submitting prior authorizations to Prime on December 22, 2025, for dates of service January 1, 2026, or later.
Lists of the medications reviewed by Prime can be found on the following sites:
- Commercial – Coming soon
- Medicaid - Coming soon
- Medicare Advantage plans (including SCO and One Care) - Part B Medical Drugs Requiring Prior Authorization list
- As mentioned in the above FAQ, Medicare Advantage (including SCO and One Care) will use CMS’ NCDs and LCDs.
Prime will only manage reviews for drugs that fall under the medical benefit for the plans listed above. For information on how to submit coverage requests to Optum Rx beginning January 1, 2026 or later for drugs that fall under the pharmacy benefit, please refer to MGBHP.org/providers/pharmacy-guidelines for Commercial and Medicaid, and MGBAdvantage.org/plans/rx-information for Medicare Advantage (including SCO and One Care).
For Commercial/QHP and MassHealth, specialty medications obtained through the pharmacy benefit that were previously reviewed by Specialty Fusion will be reviewed by Optum Rx effective January 1, 2026.
The below grid has been created to help identify which categories each pharmacy related vendor reviews.
| Commercial/QHP and MassHealth | Medicare Advantage* | ||
Before 01/01/2026 | After 01/01/2026 | Before 01/01/2026 | After 01/01/2026 | |
Non-Specialty Prior Authorization Review (Pharmacy Benefit) | Optum Rx Phone: 800-711-4555 Fax: 844-403-1029 | Optum Rx Phone: 800-711-4555 Fax: 844-403-1029 | CVS Caremark Phone: 855-344-0930 Fax: 855-633-7673 | Optum Rx Phone: 800-711-4555 Fax: 844-403-1028 |
Specialty Prior Authorization Review (Pharmacy Benefit) | Specialty Fusion Phone: 877-519-1908 Fax: 855-540-3693 | Optum Rx Phone: 800-711-4555 Fax: 844-403-1029 | CVS Caremark Phone: 855-344-0930 Fax: 855-633-7673 | Optum Rx Phone: 800-711-4555 Fax: 844-403-1028 |
Medical Drug Prior Authorization Review | Specialty Fusion Phone: 877-519-1908 Fax: 855-540-3693 | Prime Therapeutics Phone: 833-895-2611 Fax: 888-656-6671 | Novologix Phone: 855-833-3668 Fax: 833-898-3103 | Prime Therapeutics Phone: 833-895-2611 Fax: 888-656-6671 |
Medical Drug Appeals Level 1 | Mass General Brigham Health Plan | Prime Therapeutics Phone: 833-895-2611 Fax: 888-656-6671 | Mass General Brigham Health Plan | Mass General Brigham Health Plan |
*Medicare Advantage plans as identified previously.
Yes, in addition to routine updates, our Commercial/QHP plans will implement Prime drug policies. For further details, please consult the upcoming Provider Newsletter. Medicare Advantage (including SCO and One Care) will use CMS’ NCDs and LCDs.
Policies for MGBHP’s plans can be found on the following sites:
- Commercial - http://www.GatewayPA.com
- Medicaid - https://massgeneralbrighamhealthplan.org/providers/pharmacy-guidelines/masshealth
- Medicare Advantage plans (including SCO and One Care) - http://www.GatewayPA.com.
- Medicare Advantage plans will use CMS’ NCDs and LCDs.
For more information about prior authorizations, providers can call the Medical Pharmacy Solutions team at Prime Therapeutics (Prime) at 833-895-2611.
Providers directly contracted with MGBHP may request urgent and non-urgent authorizations on the Prime secure provider portal at www.GatewayPA.com. Providers may also call Prime for urgent authorization requests at 833-895-2611. Hours of operation are 8 a.m. – 8 p.m. for routine requests, and 24 hours per day/7 days per week for urgent requests.
To expedite prior authorizations, the provider should have the following information:
- Member name, date of birth and ID number
- Health plan name
- Member height and weight
- Ordering provider name, tax ID number, NPI, practice address, and office telephone and fax numbers
- Rendering provider name, tax ID number, NPI, practice address, and office telephone and numbers (if different from ordering provider)
- Requested medication name or HCPCS code
- Anticipated start date of treatment
- Dosing information and frequency
- Diagnosis (ICD-10 code)
- Any additional clinical information pertinent to the request
If requested by Prime, the provider should be prepared to upload the following documents to the Prime provider portal, or to fax the following documents to Prime’s HIPAA-compliant fax:
- Clinical notes
- Pathology reports
- Relevant lab test results
Please note: It is the responsibility of the ordering provider to obtain prior authorization before services are provided. If the ordering provider and the rendering provider are different, the rendering provider is responsible for ensuring that the appropriate approval is on file prior to rendering services.
Prime Provider Portal
Providers directly contracted with MGB may request access to the Prime provider portal. To do so, visit Prime’s provider portal at www.GatewayPA.com and complete the following steps:
- Click on New Provider Access Request under the sign in box.
- Complete the form and click “Register”.
Please have the following information ready:
- Requestor’s name, email address, and phone number
- Health plan name
- Provider, facility, or group name
- Provider, facility, or group service address
- Tax ID number
- NPI
- Practice Administrator name and email address (if not the requestor)
Please allow up to two business days for a response by email.
- You can send a message to Prime through the provider portal if the provider is directly contracted with MGB.
- If it is an urgent request, you can call Prime at 833-895-2611.
No. Prime provider portal users linked to the practice TIN will be able to conduct transactions for every network clinician linked to the practice TIN.
Prior authorization requests
Providers and their staff will have the opportunity to obtain prior authorizations to help streamline medication administration and service.
- If a prior authorization request does not initially have sufficient evidence to be approved, it is pended to be clinically reviewed by Prime’s clinical pharmacists.
- If the initial clinical reviewer finds the request meets clinical criteria, the initial clinical reviewer can approve the prior authorization request.
- If the initial clinical reviewer cannot find sufficient evidence to approve the request, he/she will schedule a peer-to-peer conversation between the provider and a Prime peer clinical reviewer, who is a board-certified physician. The Prime peer clinical reviewer will render the final determination based on the information received.
Note: Prime initial clinical reviewers are clinical pharmacists.
Yes. In most cases, approvals can be made based on the initial information provided to Prime by the requestor. If there is a question or concern regarding the information provided, the case will be sent to a pharmacist who will reach out to the requesting provider. If the pharmacist cannot reach an agreement regarding the appropriate course of treatment with respect to the requested medication, the case will be escalated to a Prime physician. A Prime physician will discuss the case with the provider. They will make a mutual decision, in accordance with plan guidelines, on an appropriate course of action.
The ordering provider, rendering provider (if different from ordering) and member receive copies of the final determination notices.
The outpatient facility will receive a copy of the approval letter and can view the status of the approval via Prime’s provider portal www.GatewayPA.com.
After an approval is generated, a change in dose and/or frequency may be requested via phone at 833-895-2611 (preferred) or via fax at 888-656-6671. Retroactive requests may also be requested via phone at 833-895-2611 (preferred) or via fax at 888-656-6671. Currently, the portal does not support backdated or retro authorizations.
There is one prior authorization number per medication. However, Prime can process multiple requests via a single portal session or telephone call.
Transition of care
Authorizations approved for dates of service before 1/1/2026, for the medications included in this program will be effective until the authorization end date*. To continue treatment after the original authorization end date, you must obtain an authorization from Prime prior to the expiration date.
*Please note: For Commercial/HIX and Medicaid, updates are being made as part of the annual review process. If formulary updates affect an authorization, members and providers will receive notifications through the current processes.
Claims
Provider trainings for Prime Therapeutics
It is recommended that you reserve your spot in one of these education sessions at least one week ahead of time. You will receive a registration confirmation email from Prime for the webinar session you select, including instructions for dialing in by phone should you need to do so. You will only need to attend one of the below educational sessions.
| Date | Time | Registration |
| Wednesday, November 19, 2025 | 9-10 a.m. (EST) | https://bit.ly/3G5MF7m |
| Wednesday, November 19, 2025 | 1-2 p.m. (EST) | https://bit.ly/4lawVzm |
| Wednesday, December 3, 2025 | 9-10 a.m. (EST) | https://bit.ly/3I8Q0mX |
| Wednesday, December 3, 2025 | 1- 2 p.m. (EST) | https://bit.ly/40tnwui |
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