Medical specialty and pharmacy policies
IMPORTANT COVID-19 INFORMATION: During the COVID-19 public health emergency, some of our medical specialty and pharmacy policies may be superseded by the information on our COVID-19 FAQ.
Prior authorization information
Medications obtained through the medical benefit
Most medications covered on the medical benefit require prior authorization through Novologix (NLX). Click here for a list of the medications authorized by Novologix*
Helpful information
- Read our authorization process for off label medical specialty medication requests.
- Our PA processes are slightly different for providers who are contracted with Mass General Brigham Health Plan but not participating in one or more of our limited network products. Read our prior authorization reference guide for limited network products.
- For new-to-market, request authorization through Novologix (NLX). Reference the new-to-market drug policy below for more information.
- For out of network providers, requesting service for a non-PPO member, request authorization through Mass General Brigham Health Plan.
*Please note: This list is not inclusive of all medications that require prior authorization by Mass General Brigham Health Plan. This list is specific to covered medications reviewed by NLX only.
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How to submit authorizations to NovoLogix
Online: Access the NovoLogix online prior authorization tool through the Provider portal
Phone: 844-345-2803 | Fax: 844-851-0882
Standard Prior Authorization Form | Standard Oncology Prior Authorization Form*
*Please note: For Commercial/Exchange members - Requests for medications used for the treatment of Cancer, including supporting medications, must be submitted on the Standard Oncology Prior Authorization Form.Check the top of the criteria document for additional information, including program details, benefit designation, and contact information.
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How to submit authorizations to Mass General Brigham Health
Providers who are outside of Mass General Brigham Health Plan provider network, requesting service for a non-PPO member, can submit requests online through the online authorization submission form.
Medications obtained through the pharmacy benefit
For medications covered on the pharmacy benefit, please submit prior authorizations through CVS Caremark using the information below.
To find out if a medication requires prior authorization or if it is listed on our formulary* please search the drug look up tool.
*Please note: Medications not listed in the drug look up tool are considered non-formulary and require a medical necessity prior authorization for coverage.
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Specialty medications
Phone: 866-814-5506 | Fax: 866-249-6155
Standard Prior Authorization Form | Standard Hepatitis C Prior Authorization Form | Standard Synagis Prior Authorization Form | Standard Oncology Prior Authorization Form*
*Please note: For Commercial/Exchange members - requests for medications used for the treatment of Cancer, including supporting medications, must be submitted on the Standard Oncology Prior Authorization Form.
Check the top of the criteria document for additional information, including program details, benefit designation, and contact information. -
Non-specialty medications
Commercial | Phone: 800-294-5979 | Fax: 888-836-0730
Health Connector | Phone: 855-582-2022 | Fax: 855-245-2134
MassHealth | Phone: 877-433-7643 | Fax: 866-255-7569
Standard Prior Authorization Form
Check the top of the criteria document for additional information, including program details, benefit designation, and contact information.
Site of care – home infusion policy
For Mass General Brigham Health Plan members, except My Care Family and Mass General Brigham employees, drugs on this list must be administered in the home setting.
To request other, medically necessary sites of care, please submit a prior authorization through NovoLogix. View the policy.
Medical specialty and pharmacy drug policies
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A - E
Abilify Mycite (Commercial/Exchange)
Acne & Rosacea (Commercial/Exchange)
Afinitor & Afinitor Disperz (MassHealth)
Alogliptin/metformin (MassHealth)
Amondys 45 (Commercial/Exchange)
Amvuttra (Commercial/Exchange)
Angiotensin II Receptor Blockers (MassHealth)
Anti-Migraine Quantity Limit (Commercial/Exchange)
Anti-Migraine Quantity Limit (MassHealth)
Apretude (Commercial/Exchange)
Aralast NP (Commercial/Exchange)
Aristada & Aristada Initio (MassHealth)
Armodafinil (Commercial/Exchange)
Attention Deficit Hyperactivity Disorder (Commercial/Exchange)
Attention Deficit Hyperactivity Disorder (MassHealth)
Atypical Antipsychotics (Commercial/Exchange)
Avastin (Ocular Disorders) (Commercial/Exchange)
Avastin (Oncology) (Commercial/Exchange)
Bactroban (Commercial/Exchange)
Belsomra (Commercial/Exchange)
Benlysta (Commercial/Exchange)
Besponsa (Commercial/Exchange)
Beta Agonists-Short Acting Oral Inhalation Limit
Bortezomib (Commercial/Exchange)
BPH-Alpha-1 Adrenergic Blockers
Brand Preferred Over Generic (Commercial/Exchange)
Brand Preferred Over Generic (MassHealth)
Brineura (Commercial/Exchange)
Bronchitol (Commercial/Exchange)
Brukinsa (Commercial/Exchange)
Bunavail (Commercial/Exchange)
Buprenorphine sublingual tablet (MassHealth)
Bynfezia (Commercial/Exchange)
Cabenuva (Commercial/Exchange)
Carbaglu (Commercial/Exchange)
Cerezyme (Commercial/Exchange)
Cialis for BPH (Commercial/Exchange)
Citalopram Capsules (MassHealth)
Corlanor (Commercial/Exchange)
Cosentyx (Commercial/Exchange)
COVID 19 OTC testing kits (MassHealth)
Crysvita (Commercial/Exchange)
Cystaran (Commercial/Exchange)
Dalfampridine ER (Ampyra) (Commercial/Exchange)
Dalfampridine ER (Ampyra) (MassHealth)
Daliresp (Commercial/Exchange)
Danyelza (Commercial/Exchange)
Daurismo (Commercial/Exchange)
Descovy for PrEP (Commercial/Exchange)
Dexcom 6 (Commercial/Exchange)
Diacomit (Commercial/Exchange)
Dihydroergotamine mesylate nasal spray (Commercial/Exchange)
Dihydroergotamine mesylate nasal spray (MassHealth)
Doptelet (Commercial/Exchange)
Doxepin cream (Commercial/Exchange)
Doxylamine with pyridoxine (Commercial/Exchange)
Doxylamine with pyridoxine (MassHealth)
Dupixent (Commercial/Exchange)
Elaprase (Commercial/Exchange)
Emgality (Commercial/Exchange)
Empaveli (Commercial/Exchange)
Enspryng (Commercial/Exchange)
Epidiolex (Commercial/Exchange)
Eprontia (Commercial/Exchange)
Exkivity (Commercial/Exchange)
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F - M
Fabrazyme (Commercial/Exchange)
Factor IX & Factor IX Complex (MassHealth)
Factor IX (Commercial/Exchange)
Factor IX Complex (Commercial/Exchange)
Factor VIII (Commercial/Exchange)
Fensolvi (Commercial/Exchange)
Fintepla (Commercial/Exchange)
Firdapse (Commercial/Exchange)
Follitropins (Commercial/Exchange)
FreeStyle Libre Products (Commercial/Exchange)
FreeStyle Libre Products (MassHealth)
Fulphila (Commercial/Exchange)
Galafold (Commercial/Exchange)
Gamifant (Commercial/Exchange)
Genotropin (Commercial/Exchange)
Givlarri (Commercial/Exchange)
Glaucoma (Commercial/Exchange)
Gvoke & Gvoke Hypo (Commercial/Exchange)
Haegarda (Commercial/Exchange)
Hepatitis C (Commercial/Exchange)
Herceptin & Herceptin Hylecta (Commercial/Exchange)
HMG-Co-A Reductase Inhibitors & Ezetimibe Products (MassHealth)
Humatrope (Commercial/Exchange)
Hyaluronates (Commercial/Exchange)
Hypnotics (Commercial/Exchange)
Imcivree (Commercial/Exchange)
Immunomodulator Quantity Limit (MassHealth)
Infertility (Commercial/Exchange)
Inflectra (Commercial/Exchange)
Infliximab (Commercial/Exchange)
Influenza Treatment & Prevention Quantity Limit
Intrarosa (Commercial/Exchange)
Invega Hafyera, Invega Sustenna, & Invega Trinza (MassHealth)
Isturisa (Commercial/Exchange)
Itrazonazole (Commercial/Exchange)
Jemperli (Commercial/Exchange)
Juxtapid (Commercial/Exchange)
Kalydeco (Commercial/Exchange)
Kerendia (Commercial/Exchange)
Kesimpta (Commercial/Exchange)
Kimmtrak (Commercial/Exchange)
Kisqali-Femara Co-Pack (MassHealth)
Krintafel (Commercial/Exchange)
Kyprolis (Commercial/Exchange)
Lemtrada (Commercial/Exchange)
Leukotriene Inhibitors (Commercial/Exchange)
Leukotriene Inhibitors (MassHealth)
Livmarli (Commercial/Exchange)
Livtencity (Commercial/Exchange)
Long-Acting Cerebral Stimulants (MassHealth)
Lorbrena (Commercial/Exchange)
Lucemyra (Commercial/Exchange)
Lucentis (Ocular Disorders) (Commercial/Exchange)
Lumakras (Commercial/Exchange)
Lupkynis (Commercial/Exchange)
Macugen (Ocular Disorders) (Commercial/Exchange)
Makena (hydroxyprogesterone caproate)
Mandatory Generic Policy (Commercial/Exchange)
Mandatory Generic Policy (MassHealth)
Margenza (Commercial/Exchange)
Mavenclad (Commercial/Exchange)
Mepsevii (Commercial/Exchange)
Modafinil (Commercial/Exchange)
Motegrity (Commercial/Exchange)
Mounjaro (Commercial/Exchange)
Movantik (Commercial/Exchange)
Mulpleta (Commercial/Exchange)
Mupirocin cream (Commercial/Exchange)
Mvasi (Oncology) (Commercial/Exchange)
Mycapssa (Commercial/Exchange)
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N - Z
Nasal Steroids (Commercial/Exchange)
Nascobal (Commercial/Exchange)
Nayzilam (Commercial/Exchange)
Neulasta (Commercial/Exchange)
Neupogen (Commercial/Exchange)
New to Market Medications (Commercial/Exchange)
New to Market Medications (MassHealth)
Nexletol (Commercial/Exchange)
Nexlizet (Commercial/Exchange)
Nivestym (Commercial/Exchange)
Non-Formulary Diabetic Supplies & Test Strip Quantity Limit (Commercial/Exchange)
Non-Formulary Medications (Commercial/Exchange)
Non-Formulary Medications (MassHealth)
Norditropin (Commercial/Exchange)
Nourianz (Commercial/Exchange)
Novoseven RT (Commercial/Exchange)
Nuedexta (Commercial/Exchange)
Nutropin AQ (Commercial/Exchange)
Nyvepria (Commercial/Exchange)
Octreotide (Sandostatin) (Commercial/Exchange)
Octreotide (Sandostatin) (MassHealth)
Olumiant (Commercial/Exchange)
OmniPod & OmniPod Dash (Commercial/Exchange)
OmniPod, Omnipod 5, & OmniPod Dash (MassHealth)
Omnitrope (Commercial/Exchange)
Onpattro (Commercial/Exchange)
Ontruzant (Commercial/Exchange)
Opdualag (Commercial/Exchange)
Ophthalmic NSAIDs (Commercial/Exchange)
Ophthalmic NSAIDs (MassHealth)
Ophthalmic Steroids (Commercial/Exchange)
Ophthalmic Steroids (MassHealth)
Opioids ER - Step Therapy with MME Limit & Post Limit
Opioids IR - 7-Day Acute Pain Duration Limit with MME Limit & Post Limit
Opioids IR - 7-Day APAP-ASA-IBU Combo Products - Acute Pain Duration Limit
Opzelura (Commercial/Exchange)
Orilissa (Commercial/Exchange)
Orladeyo (Commercial/Exchange)
Osmolex ER (Commercial/Exchange)
Overactive Bladder (Commercial/Exchange)
Overactive Bladder (MassHealth)
Oxervate (Commercial/Exchange)
Oxtellar XR (Commercial/Exchange)
Palforzia (Commercial/Exchange)
Palynziq (Commercial/Exchange)
Pediatric Behavioral Health Medication Initiative (MassHealth)
Pemazyre (Commercial/Exchange)
Perforomist (Commercial/Exchange)
Pimecrolimus 1% cream (Commercial/Exchange)
Poteligeo (Commercial/Exchange)
Praluent (Commercial/Exchange)
Pretomanid (Commercial/Exchange)
Pretomonid (Commercial/Exchange)
Prevymis (Commercial/Exchange)
Prolastin-C (Commercial/Exchange)
Promacta (Commercial/Exchange)
Proton Pump Inhibitors (Commercial/Exchange)
Proton Pump Inhibitors (MassHealth)
Pyridostigmine bromide 30mg tablet
Quantity Limit (Commercial/Exchange)
Quzyttir (Commercial/Exchange)
Radicava & Radicava ORS (Commercial/Exchange)
Radicava & Radicava ORS (MassHealth)
RAGWITEK (Commercial/Exchange)
Reblozyl (Commercial/Exchange)
Recorlev (Commercial/Exchange)
Relistor (Commercial/Exchange)
Remicade (Commercial/Exchange)
Renflexis (Commercial/Exchange)
Repaglinide/metformin (MassHealth)
Restasis (Commercial/Exchange)
Retacrit (Commercial/Exchange)
Riomet & Riomet ER (MassHealth)
Rituxan & Rituxan Hycela (Commercial/Exchange)
Rituxan & Rituxan Hycela (MassHealth)
Ruxience (Commercial/Exchange)
Rybelsus (Commercial/Exchange)
Rybrevant (Commercial/Exchange)
Ryplazim (Commercial/Exchange)
Sandostatin LAR (Commercial/Exchange)
Saphnelo (Commercial/Exchange)
Scemblix (Commercial/Exchange)
Scenesse (Commercial/Exchange)
SevenFact (Commercial/Exchange)
Signifor LAR (Commercial/Exchange)
Signifor and Signifor LAR (MassHealth)
Simponi Aria (Commercial/Exchange)
Skeletal Muscle Relaxants (Commercial/Exchange)
Skeletal Muscle Relaxants (MassHealth)
Skytrofa (Commercial/Exchange)
Solaraze (diclofenac sodium gel)
Somavert (Commercial/Exchange)
Spinraza (Commercial/Exchange)
Sporanox oral solution (Commercial/Exchange)
Sporanox oral solution (MassHealth)
Spravato (Commercial/Exchange)
Suboxone (Commercial/Exchange)
Susvimo (Ocular Disorders) (Commercial/Exchange)
Tacrolimus 0.03% & 0.1% ointment (Commercial/Exchange)
Tagrisso (Commercial/Exchange)
Takhzyro (Commercial/Exchange)
Talzenna (Commercial/Exchange)
Tascenso (Commercial/Exchange)
Tavalisse (Commercial/Exchange)
Terbinafine 250mg Quantity Limit (Commercial/Exchange)
Terbinafine 250mg Quantity Limit (MassHealth)
Teriparatide (Commercial/Exchange)
Testopel (Commercial/Exchange)
Testosterone Products (Commercial/Exchange)
Testosterone Products (MassHealth)
Tetrabenazine (Commercial/Exchange)
Tezspire (Commercial/Exchange)
Thiazolidinedione Containing Products (Commercial/Exchange)
Thiazolidinedione Containing Products (MassHealth)
Tiglutik (Commercial/Exchange)
Tivicay Quantity Limit (MassHealth)
Topical Corticosteroids (Commercial/Exchange)
Topical Corticosteroids (MassHealth)
Topical Corticosteroids Quantity Limit
Topical Vitamin D Analog (Commercial/Exchange)
Topical Vitamin D Analog (MassHealth)
Trazimera (Commercial/Exchange)
Trikafta (Commercial/Exchange)
Trintellix (Commercial/Exchange)
Triptodur (Commercial/Exchange)
Trodelvy (Commercial/Exchange)
Trogarzo (Commercial/Exchange)
Trokendi XR (Commercial/Exchange)
Trulance (Commercial/Exchange)
Trulicity (Commercial/Exchange)
Truseltiq (Commercial/Exchange)
Ultomiris (Commercial/Exchange)
Vabysmo (Ocular Disorders) (Commercial/Exchange)
Venlafaxine besylate (MassHealth)
Vilazodone (Commercial/Exchange)
Viltepso (Commercial/Exchange)
Visudyne (Ocular Disorders) (Commercial/Exchange)
Vizimpro (Commercial/Exchange)
Vumerity (Commercial/Exchange)
Vyndagel (Commercial/Exchange)
Vyndamax (Commercial/Exchange)
Vyondys 53 (Commercial/Exchange)
Weight Loss (Commercial/Exchange)
Xarelto 2.5 & Xarelto Suspension (MassHealth)
Xeljanz & Xeljanz XR (Commercial/Exchange)
Xeljanz and Xeljanz XR (MassHealth)
Xenpozyme (Commercial/Exchange)
Xifaxan 500mg (Commercial/Exchange)
Zelapar ODT (Commercial/Exchange)
Ziextenzo (Commercial/Exchange)
Zirabev (Oncology) (Commercial/Exchange)
Zomactan (Commercial/Exchange)
Zulresso (Commercial/Exchange)
