Medical Benefit Prior Authorization Medication List
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Lists medications that require prior authorization when provided under the member's medical benefit in certain outpatient settings and identifies member types to which the requirement applies.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization criteria and applicability
Covered when ALL of the following are met:
ALL of the following
Applicable settings
- Clinician's or physician's office
- Home health care provider
- Home infusion therapy provider
- Outpatient hospital
- Dialysis
ALL of the following
Applicable member types
- Commercial HMO members
- POS members
- Access Blue members with a Massachusetts-based primary care provider
- Commercial EPO members
- Commercial PPO members
ALL of the following
Exceptions
- Blue Choice members using the self-referred benefit — authorization is not required
- Some medications or subcutaneous formulations may not have medical benefit coverage; refer to Provider Central lists
Coding and Effective Date Context
| No codes listed |
Provider Requirements and Exceptions
Prior Authorization Required
Authorization is required for these medications when administered using a member's medical benefit in the following outpatient settings: Clinician's or physician's office; home health care provider; home infusion therapy provider; outpatient hospital; dialysis.
- Applies to commercial HMO, POS*, and Access Blue members* who have a Massachusetts-based primary care provider
- Applies to commercial EPO and PPO members
Exceptions and Benefit Notes
Blue Choice self-referred benefit exception and benefit notes: For Blue Choice members, an authorization is not required if using the self-referred benefit. The member may not have medical benefits for certain medications or for subcutaneous formulations — refer to the Provider Central lists of medications that are not covered by medical benefits.
- Policy 034 Medical Benefit Prior Authorization Medication List (As of 5/1/2026)
- Note: The Member may not have medical benefits for this medication. Please refer to our list of medications that aren't covered by medical benefits located on Provider Central.
- Note: The member may not have medical benefits for the subcutaneous version of this medication. Refer to our list of medications that aren't covered by medical benefits located on Provider Central.
Key Definitions and Notes
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