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

• Commercial – Commercial Medical Drugs Requiring Prior Authorization list
• Medicaid - MGB ACO Medical Drugs 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. 

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 https://MGBHP.org/providers/pharmacy-guidelines for Commercial and Medicaid and MGBAdvantage.org 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.

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.

There is one prior authorization number per medication. However, Prime can process multiple requests via a single portal session or telephone call.