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.

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.

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.