Commercial medical specialty and pharmacy policies
Prior authorization information
Medications obtained through the medical benefit
Most medications covered on the medical benefit require prior authorization through Prime Therapeutics. Click here for a list of the medications authorized by Prime Therapeutics.*
Helpful information
- 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 Prime Therapeutics. Reference the new-to-market drug policy below for more information.
- For out-of-network providers, requesting service for a non-PPO member, Prime Therapeutics will review the medical necessity of the medication. Authorization for the member to go outside of the network must be submitted separately to the 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 medical specialty medications that require authorization through Prime Therapeutics only.
Online: Access the Prime Therapeutics online prior authorization tool through the Provider Portal or through the Prime secure provider portal at www.GatewayPA.com.
Phone: 833-895-2611 | Fax: 888-656-6671
Standard Prior Authorization Form | Standard Oncology Prior Authorization Form*
*Please note: 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.
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 to Optum Rx 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.
Phone: 800-711-4555 | Fax: 844-403-1029
Standard Prior Authorization Form | Standard Hepatitis C Prior Authorization Form | Standard Synagis Prior Authorization Form | Standard Oncology Prior Authorization Form*
*Please note: 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.
Questions about pharmacy guidelines?
Call Provider Services at 855-444-4647.
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