CurrentBlue Cross Blue Shield - MassachusettsPolicy 034

Medical Benefit Prior Authorization Medication List

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.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedical Benefit Prior Authorization Medication List

Policy CodePolicy Policy 034

Change TypeNo material change

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization when medications on the list are administered under the member's medical benefit in outpatient settings for applicable commercial member types.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>200medications listed for prior authorization

5settings where authorization is required

commercial HMO/POS/EPO/PPOmember types subject to authorization

Policy 033related pharmacy medical policy referenced

Prior Authorization Coverage Criteria

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Prior authorization criteria and applicability

Covered when ALL of the following are met:

Prior authorization is required for medications listed on Policy 034 when administered under the member's medical benefit in specified outpatient settings.

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 specific procedure or billing codes providedmixed

No codes listed

Effective / listing date context

ContextEntries in the medication list include adjacent effective or listing dates (e.g., Abrilada = 1/1/2024; Actemra = 8/1/2025; Adalimumab-aacf = 7/1/2025).

Practical implicationDates shown next to medication names indicate the effective or listing date for that specific product entry in the policy list (as of 5/1/2026).

ScopeThe alphabetized medication list contains over 200 drug entries with many entries annotated by dates.

Notation examplesExamples from the list: Abrilada = 1/1/2024; Actemra = 8/1/2025; Adalimumab-adaz = 1/1/2024.

Source datePolicy list effective snapshot: as of 5/1/2026.

Provider Requirements and Exceptions

Prior Authorization

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

Note

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

Authorization requirement summary

Requirement summaryPrior authorization is required when medications are administered using the member's medical benefit in the following outpatient settings: clinician's/physician's office; home health care provider; home infusion therapy provider; outpatient hospital; dialysis.

Applicable member typesApplies to commercial HMO, POS, and Access Blue members who have a Massachusetts‑based primary care provider, and to commercial EPO and PPO members.

Benefit contextThis requirement applies specifically when the medication is billed under the member's medical benefit (medical‑benefit administrations in listed outpatient settings).

Action for providersObtain prior authorization before administering listed medications under the medical benefit in the specified outpatient settings for the listed commercial member types.

Blue Choice self‑referred benefit exception

ExceptionBlue Choice members using the self‑referred benefit do not require prior authorization for these medications.

Coverage noteSome medications or subcutaneous formulations may not have medical benefit coverage; providers should refer to Provider Central for lists of medications not covered by medical benefits.

Operational hintIf a Blue Choice member accesses care through the self‑referred benefit, providers may proceed without obtaining prior authorization for medications on this list, but should confirm benefit coverage when applicable.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedical Benefit Prior Authorization Medication List

Policy CodePolicy Policy 034

Change TypeNo material change

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization when medications on the list are administered under the member's medical benefit in outpatient settings for applicable commercial member types.

SourceLink

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