MassHealth 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.
• For specialty new-to-market, request authorization through Specialty Fusion. Reference the new-to-market drug policy below for more information.
• For providers outside of the MGB ACO network, 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 the MassHealth formulary please search the MassHealth Drug List.

Pharmacy policies

Please note, the following policies are pharmacy benefit drugs that are not aligned with MassHealth. If a policy is not listed below search the MassHealth Drug List for criteria.

Massachusetts Step Therapy Protocol Exception

New to Market

Off-Label/Non-FDA Approved Indications

Plan Exclusions

Quantity Limit