Medical Specialty Medications — MassHealth Prior Authorization Code List
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This document lists medical specialty medications and associated billing codes and attributes for MassHealth prior authorization effective 05/01/2026; it governs prior authorization handling for these specialty drugs under the Mass General Brigham Health Plan for the MassHealth program.
No material clinical or coverage changes in this revision.
Coverage criteria and administrative flags
Medication code inventory
Code list with attributes — the document provides a roster of specialty medication billing codes and per-code administrative flags; no itemized clinical medical-necessity rules are included in this section.
ALL of the following
- Each code entry includes administrative attributes: Dual Benefit, HCT (hematopoietic cell transplant), DW Program (Drug Wastage Program), PD-1 Weight Based Dosing, and IVIG Dose Optimization with Y/N or blank values.
- This section is an inventory; it does not define clinical coverage criteria or step-therapy rules within these chunks.
ALL of the following
Coverage stance for listed medications
Top-level observation on coverage stance and document purpose:
ALL of the following
- The listed entries present code-level information and administrative flags intended to inform prior-authorization processing (Dual Benefit, HCT, DW Program, PD-1 weight-based dosing, IVIG Dose Optimization).
- The excerpt does not include itemized medical necessity rules, clinical criteria, or explicit coverage determinations for individual diagnoses or indications; it functions as an administrative inventory to guide routing and handling during prior authorization review.
ALL of the following
- Dual Benefit is indicated for a subset of products (flagged as Y) and will affect billing/benefit handling where applicable.
Administrative coverage flags and meaning
Definitions and operational meaning of per-entry administrative flags used in prior-authorization handling:
See PD‑1 weight‑based dosing flags for nivolumab/opdivo class entries.
Partial medication entries
Representative partial entries from the roster (attributes shown as recorded in the source):
Coverage stance (partial)
Summary observations for the specialty medication coding excerpt (partial):
ALL of the following
- The excerpt enumerates additional HCPCS/J/Q codes with brand/generic names and repeated administrative flags (Dual Benefit, HCT, DW Program, PD‑1 Wt Based Dosing, IVIG Dose Optimization) for routing and prior‑authorization handling.
- This portion does not provide explicit medical necessity criteria or step‑therapy rules for these specialty medications; it should be used as an administrative inventory to support authorization workflows.
HCPCS / J- / Q-code listings and attributes
| Q5100 | ustekinumab-kfce / Yesintek SQ (brand/generic indicated) |
| J9278 | intravenous immune globulin / Yimmugo |
| Q5141 | adalimumab-aaty / Yuflyma |
| J3590 | adalimumab-aqvh / Yusimry |
| J9400 | ziv-aflibercept / Zaltrap |
| J9223 | lurbinectedin / Zepzelca |
| J9276 | zanidatamab / Ziihera |
| J3304 | triamcinolone acetonide / Zilretta |
| Q5118 | bevacizumab-bvzr / Zirabev |
| J9202 | goserelin acetate implant / Zoladex |
What providers must know and do (billing & prior auth impacts)
Specialty medication code and attribute list — codes and flags
Q5145 (Abrilada) — adalimumab-afzb; Dual Benefit = Y; HCT = N; DW Program = N; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N. J3262 (Actemra IV) — tocilizumab; Dual Benefit = .; HCT = N; DW Program = N; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N. J0791 (Adakveo) — crizanlizumab-tmca; Dual Benefit = .; HCT = N; DW Program = Y; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N. J9042 (Adcetris) — brentuximab vedotin; Dual Benefit = .; HCT = N; DW Program = Y; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N. J7171 (Adzynma) — ADAMTS13, recombinant-krhn; Dual Benefit = Y; HCT = N; DW Program = N; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N. Q5150 (Ahzantive) — aflibercept-mrbb; Dual Benefit = .; HCT = N; DW Program = N; PD-1 Wt Based Dosing = N; IVIG Dose Optimization = N.
Specialty medication listing and flags — document these attributes on PA
Entries include code, brand/generic name, and administrative flags; providers must document code-specific attributes on prior authorization requests (e.g., Dual Benefit, HCT, DW Program, PD-1 weight‑based dosing, IVIG Dose Optimization) because these flags determine routing and handling during PA processing.
Medication code list and flags (partial) — PA-relevant flags shown
Q5107 (Mvasi) — bevacizumab-awwb; J0221 (Lumizyme) — alglucosidase alfa; J1568 (Octagam) — intravenous immune globulin (IVIG Dose Optimization = Y); J2350 — PD‑1 Wt Based Dosing = N. These partial entries include program flags relevant to prior authorization handling.
Specialty medication code list (partial) — HCPCS/J/Q codes with flags
Selected HCPCS entries with flags: J2327 (IVIG Dose Optimization = N); J7331 (Sodium hyaluronate) — Dual Benefit = .; HCT = N; Q5114 (Ogivri) — IVIG Dose Optimization = N; J3590 (Somavert) — Dual Benefit = Y. Providers should reference these flags when submitting PA requests.
Specialty medication code attributes (partial) — flags to include on PA
Attributes shown for select codes include brand/generic and markers such as Dual Benefit, HCT, DW Program, PD‑1 Wt Based Dosing, and IVIG Dose Optimization. Examples: Q5100 (Yesintek SQ) — Dual Benefit = Y; J9278 (Yimmugo) — IVIG Dose Optimization = Y; Q5141 (Yuflyma) — Dual Benefit = Y.
Additional specialty medication entries — include flag details on PA
Additional listed entries require flag-aware submission: J9223 (Zepzelca) — DW Program = N; J9276 (Ziihera) — DW Program = N; J1748 (Zymfentra / infliximab-dyyb) — Dual Benefit = Y. Include these code flags in PA paperwork to ensure correct program routing.
Flags and attribute definitions
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