MassHealth (Medicaid) 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
- For new-to-market, request authorization through Prime Therapeutics. Reference the new-to-market drug policy below for more information.
- For providers outside of the MGB ACO network, 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
MassHealth Prior Authorization Form | Standard 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 the MGB ACO network 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 the MassHealth formulary, please search the MassHealth Drug List.
Phone: 800-711-4555 | Fax: 844-403-1029
MassHealth Prior Authorization Form | Standard Prior Authorization Form
Check the top of the criteria document for additional information, including program details, benefit designation, and contact information.
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
Off-Label/Non-FDA Approved Indications
Medical specialty and dual benefit drug policies
Questions about pharmacy guidelines?
Call Provider Services at 855-444-4647.
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