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 Specialty Fusion. Click here for a list of the medications authorized by Specialty Fusion*

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 Specialty Fusion. Reference the new-to-market drug policy below for more information.
For out-of-network providers, requesting service for a non-PPO member, Specialty Fusion 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 Specialty Fusion only.

Online: Access the Specialty Fusion online prior authorization tool through the Provider portal
Phone: 877-519-1908 | Fax: 855-540-3693

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 non-specialty medications covered on the pharmacy benefit and non-formulary medications, please submit prior authorizations to Optum Rx using the information below.

For specialty medications, please submit prior authorizations to Specialty Fusion 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: 877-519-1908 | Fax: 855-540-3693

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.

Phone: 800-711-4555 | Fax: 844-403-1029

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 Mass General Brigham employees, drugs marked as Site of Care on this list must be administered in the home or office setting.

To request other, medically necessary sites of care, please submit a prior authorization through Specialty Fusion. View the policy.

Commercial medical specialty and pharmacy policies

Prior authorization information

Medications obtained through the medical benefit

Helpful information

How to submit authorizations to Specialty Fusion

How to submit authorizations to Mass General Brigham Health

Medications obtained through the pharmacy benefit

Specialty medications

Non-specialty and non-formulary medications

Site of care – home infusion policy

Medical specialty and pharmacy drug policies

A - E

F - M

N - Z

Questions about pharmacy guidelines?