Lists of the medications reviewed by Prime can be found on the following sites:

• Commercial/exchange – Specialty medications requiring prior authorization list
• Medicaid - Specialty medications requiring prior authorization list
• 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. 

Abbreviations in the medical specialty medication lists include:
HCT: High-Cost Therapy
DW: Drug Wastage
PD-1 Wt Based Dosing:  PD-1 Drugs Weight-Based Dose Optimization
IVIG Dose Optimization: IVIG Dosage Optimization

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.

*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. 

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.

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.

The PSCE 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
• Mass General Brigham Advantage Group

*The Medicare Part D Group PDP is not included in this program as this plan does not have Part B medical drug coverage.

Depending on the drug, claims may be evaluated for:

• Eligible diagnosis
• Maximum units or dosage
• Frequency or duration of therapy
• Loading dose validation
• Drug waste (JW modifier), when applicable

No. Some drugs may still require prior authorization, while others may be reviewed through PSCE only.

Only select drugs billed under the medical benefit are subject to PSCE. Not all drugs or claims are included. All drugs that require prior authorization through Prime Therapeutics will be subject to claim edits. In addition, the following drugs will be reviewed through PSCE only.

• Commercial/Exchange
• Medicare Advantage (including D-SNP)

Please note: Mass General Brigham ACO (MassHealth) will only have claim edits applied to drugs that require prior authorization.

If a claim does not meet applicable criteria, the explanation of payment (EOP) will indicate the reason for the adjustment or denial.

The medical policies vary based on lines of business. For drugs that require a prior authorization, PSCE will be based on the approval for each member.

Medical necessity policies for Mass General Brigham Health Plan can be found on the following sites:

• Commercial plans - 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.

To identify a member’s approved dosing and frequency, please review the member’s prior authorization approval letter and/or login to http://www.GatewayPA.com.

Please note: You may continue to view approved Prime authorizations on the Mass General Brigham Health Plan Provider Portal, but it will not be an accurate representation of dosing and/or frequency.

If the member’s authorization was approved prior to 2026 with a different vendor, those authorizations will not be subject to claims edits. Current prior authorization matching will continue to apply.

No. Continue to submit claims according to existing health plan requirements.

For questions related to the PSCE program, providers may contact the Medical Pharmacy Solutions Provider Relations team at ProviderInquiry@PrimeTherapeutics.com.