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 Novologix (NLX). Click here for a list of the medications authorized by Novologix*

Helpful information

• Read our authorization process for off label medical specialty medication requests.
• For new-to-market, request authorization through Novologix (NLX). Reference the new-to-market drug policy below for more information.
• For outside of the MGB ACO network, request authorization through Mass General Brigham Health 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 covered medications reviewed by NLX only.

Medications obtained through the pharmacy benefit

For medications covered on the pharmacy benefit, please submit prior authorizations through CVS Caremark 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.

Compounds

Opioids ER - Step Therapy with MME Limit & Post Limit

Opioids IR - 7-Day Acute Pain Duration Limit with MME Limit & Post Limit

Opioids IR - 7-Day APAP-ASA-IBU Combo Products - Acute Pain Duration Limit

Quantity Limit