Medical Benefit Prior Authorization Medication List
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Defines which medications administered under the member's medical benefit in specified outpatient settings require prior authorization and which commercial product lines and member types the requirement applies to within Massachusetts.
No material clinical or coverage changes in this revision.
Medications Requiring Prior Authorization
Medication list-based coverage with prior authorization
Medications named in Policy 034 require prior authorization when administered under the member's medical benefit in the outpatient settings listed.
ALL of the following
- Medication list: Medication is one of the specific products enumerated in Policy 034 Medical Benefit Prior Authorization Medication List (as of 3/15/2026).
Outpatient medical-benefit administration settings
- Clinician's or physician's office
- Home health care provider
- Home infusion therapy provider
- Outpatient hospital
- Dialysis
ALL of the following
Applicable commercial product lines and member types
- Commercial HMO members
- POS members
- Access Blue members (with Massachusetts-based primary care provider)
- Commercial EPO members
- Commercial PPO members
ALL of the following
Exceptions / Notes
- For Blue Choice members, an authorization is not required if using the self-referred benefit.
- Some listed medications or their subcutaneous formulations may not be covered under the member's medical benefit; providers should refer to Provider Central lists for items not covered by medical benefits.
ALL of the following
- Operational requirement: Prior authorization must be obtained when the medication is administered under the member's medical benefit in the specified outpatient settings prior to or in accordance with payer requirements.
ALL of the following
- Reference: See Policy 034 medication list (as of 3/15/2026) for the full enumerated products and effective dates; cross-reference Pharmacy Medical Policy 033 as applicable.
Prior Authorization and Provider Responsibilities
Prior Authorization Required for Medical‑Benefit Medications
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. 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.
- Affected settings: Clinician/physician office; home health care; home infusion therapy; outpatient hospital; dialysis.
- Applies to: Commercial HMO, POS, Access Blue (with MA-based PCP), and commercial EPO and PPO members.
Exceptions and Coverage Definitions
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