Medical Benefit Prior Authorization Medication List
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Lists outpatient medications that require prior authorization when billed to a member's medical benefit for specified commercial lines in Massachusetts and describes applicable outpatient settings and member categories. Affects providers administering these medications and authorization staff for Blue Cross Blue Shield Massachusetts commercial plans.
No material clinical or coverage changes in this revision.
Medications Requiring Prior Authorization
Medications requiring medical-benefit prior authorization (alphabetical list)
Medications listed below require prior authorization under the medical benefit when administered in the specified outpatient settings for applicable member types.
ALL of the following
Alphabetical medication list
- See full alphabetical list of medications in Policy 034 (pages/chunks 1–14).
ALL of the following
- Authorization is required when these medications are administered using a member's medical benefit in the following outpatient settings: clinician/physician office; home health care provider; home infusion therapy provider; outpatient hospital; dialysis.
- Authorization applies to commercial HMO, POS, and Access Blue members who have a Massachusetts-based primary care provider, and to commercial EPO and PPO members.
Exceptions / non-medical benefit formulations
Exceptions and coverage notes
ALL of the following
- Blue Choice self-referral: For Blue Choice members, an authorization is not required if using the self-referred benefit.
- Medical benefit coverage limitations: The member may not have medical benefits for some medications; refer to the Provider Central list of medications not covered by medical benefits.
- Subcutaneous formulation limitation: The member may not have medical benefits for the subcutaneous version of some medications; refer to the Provider Central list of medications not covered by medical benefits.
Authorization and Billing Actions
Medical-benefit prior authorization required for outpatient administration
Authorization is required for the listed medications when administered using a member's medical benefit in outpatient settings (clinician/physician office; home health care provider; home infusion therapy provider; outpatient hospital; dialysis). This requirement applies to commercial HMO, POS, and Access Blue members who have a Massachusetts-based primary care provider, and to commercial EPO and PPO members.
Blue Choice self-referral exception — no authorization needed
For Blue Choice members, an authorization is not required when the service is provided using the self-referred benefit.
Medical-benefit coverage limitations — check Provider Central
Some medications or their subcutaneous formulations may not be covered under the medical benefit; providers should refer to Blue Cross Blue Shield MA’s list of medications not covered by medical benefits on Provider Central.
- The Member may not have medical benefits for this medication — see Provider Central list of medications not covered by medical benefits.
- The member may not have medical benefits for the subcutaneous version of this medication — see Provider Central list.
Applicable Settings and Member Categories
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