MassHealth pharmacy formulary and prior authorization updates (multiple drugs and classes)
Customize your policy alerts
Sign up for all Mass General Brigham Health Plan policy alerts
Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.
Monitor payer policy activity
Multi-topic bulletin describing upcoming MassHealth pharmacy policy changes (effective dates primarily 2026-07-01 and 2026-08-10) including anti-obesity/GLP-1 coverage restrictions, ustekinumab biosimilar preference updates, multiple drug preference/non-preferred status and prior authorization/quantity limit changes across therapeutic classes, and assorted criteria updates.
MassHealth will no longer cover medications used solely for weight loss effective July 1, 2026, with limited exceptions.
Preferred ustekinumab biosimilars updated effective July 1, 2026; Imuldosa, Pyzchiva, and Steqeyma will no longer be preferred.
Numerous brand medications changed to non-preferred or added with prior authorization and quantity limits effective August 10, 2026.
Multiple clinical criteria updates across therapeutic areas (oncology immunotherapy, lupus agents, prostate cancer agents, pulmonary hypertension, SSTI/HABP/VABP, etc.).
What is changing — summary and key dates
This multi-topic MassHealth change bulletin summarizes upcoming pharmacy program updates affecting formulary coverage, prior authorization, step-therapy (step-through) and quantity limits across many drugs and therapeutic classes. A major coverage change removes MassHealth coverage for medications used solely for weight loss, including GLP-1 agents, effective 2026-07-01. Additional, broader formulary preference, PA and quantity-limit changes take effect on 2026-08-10, including ustekinumab biosimilar preference updates, numerous brand-to-generic non-preferred designations, and multiple clinical criteria refinements across specialties.
Anti-Obesity / GLP-1 Coverage (Effective 2026-07-01)
Provider actions
Reminder: GLP-1 and other medications prescribed solely for weight loss will no longer be covered effective 2026-07-01. Exceptions and documentation requirements below must be met to avoid denial.
- Effective date: 2026-07-01 — coverage for weight-loss-only medications ends; existing PAs remain fillable through 2026-06-30.
- Exceptions: Wegovy (semaglutide) injection/tablet covered only for specified indications (see criteria). Zepbound (tirzepatide) is non-preferred and requires step-through with Wegovy injection for OSA.
- EPSDT/pediatric: All requests for members <21 are reviewed under EPSDT. For EPSDT-eligible members new to GLP-1s (ages 12–21), step-through with phentermine and Wegovy is required; clinical rationale required if not using Wegovy.
- Diabetes comorbidity: For members with diabetes or prediabetes, include a new written prescription for an appropriate diabetic medication with the PA request.
- Quantity limits: Existing quantity limits continue to apply to approved indications; prescribers must document adherence to quantity limits on the PA request.
Ustekinumab biosimilar preference (Effective 2026-07-01)
Ustekinumab Biosimilar Preference Update (Effective 2026-07-01)
Preferred ustekinumab biosimilars will change and some products will require trials of preferred biosimilars.
Ustekinumab Biosimilar Step‑Therapy and Substitution Rules (effective 2026‑07‑01)
Preferred ustekinumab biosimilars are updated effective 2026-07-01. Imuldosa, Pyzchiva, and Steqeyma will no longer be preferred and will require trial of all preferred biosimilars. Starjemza and unbranded ustekinumab-aekn are the preferred interchangeable biosimilars and may be automatically substituted for Stelara, Pyzchiva, or Steqeyma at the pharmacy. Imuldosa cannot be automatically substituted; patients using Imuldosa will need a new prescription for Starjemza or ustekinumab-aekn (Imuldosa requires a new prescription rather than automatic substitution).
- Interchangeable biosimilars (Starjemza, ustekinumab‑aekn) may be auto‑substituted at the pharmacy for Stelara, Pyzchiva, or Steqeyma.
- Imuldosa requires a new prescription for substitution — cannot be auto‑substituted.
Brand non-preferred changes & UPPL mapping (Effective 2026-08-10)
Brand Non-Preferred Changes and UPPL Compliance (Effective 2026-08-10)
Selected brand-name medications will become non-preferred requiring trial of their generic equivalents; UPPL alignments were made.
Brand→Generic Step‑Through Requirements (effective 2026‑08‑10)
Brand‑to‑generic preference changes require trial of preferred generics/therapeutic alternatives per UPPL mapping. These brand-to-generic step‑through rules (e.g., Condolyx → Podofilox gel; Rowasa enema → mesalamine enema) take effect 2026-08-10; prescribers should document trial of the preferred generic or provide clinical rationale when requesting the non-preferred brand.
- Effective date: 2026-08-10 — non‑preferred brands will require trial of the listed generic alternative prior to approval.
Prior authorization additions and quantity limits (Effective 2026-08-10)
| Product name | Benefit (Pharmacy/Medical) | PA required (Y/N) | Quantity limit | Effective date |
|---|---|---|---|---|
| Yuviwel injection | Pharmacy | Y | 2 vials per 7 days | 2026-08-10 |
| Myqorzo tablet | Pharmacy | Y | 30 tablets per 30 days | 2026-08-10 |
| Linzess capsules | Pharmacy | Y | 30 capsules per 30 days | 2026-08-10 |
| Cardamyst 70 mg nasal spray | Pharmacy | Y | 2 units (140 mg total) per 30 days | 2026-08-10 |
| Aqvesme tablet | Pharmacy | Y | 60 tablets per 30 days | 2026-08-10 |
| Zycubo vial | Pharmacy | Y | (no quantity limit specified) | 2026-08-10 |
| Spinraza high dose (HD) vial | Medical | Y | (same criteria as low dose; quantity not specified) | 2026-08-10 |
| Lymphir injection | Medical | Y | (no quantity limit specified) | 2026-08-10 |
| Sdamlo powder for oral solution | Pharmacy | Y | (no quantity limit specified) | 2026-08-10 |
| Orladeyo pellet packet | Pharmacy | Y | (no quantity limit specified) | 2026-08-10 |
| Contepo injection | Pharmacy (PA) / Medical (no PA under medical) | Y (pharmacy); N (medical benefit) | (criteria require step-through with 2 alternatives) | 2026-08-10 |
| Zepbound (tirzepatide) | Pharmacy | Y (non-preferred; step-through required) | (step-through with Wegovy injection for OSA required) | 2026-07-01 |
| Starjemza / ustekinumab-aekn (preferred biosimilars) | Pharmacy | Y (preferred/interchangeable; used for automatic substitution) | (n/a) | 2026-07-01 |
| Imuldosa / Pyzchiva / Steqeyma (ustekinumab non-preferred) | Pharmacy | Y (require trial of preferred biosimilars) | (n/a) | 2026-07-01 |
| Kanjinti (step-through for trastuzumab agents) | Pharmacy/Medical | Y (as step-through trial) | (n/a) | 2026-08-10 |
| Contepo (listed again for clarity) | Pharmacy/Medical | Y (pharmacy); N (medical) | (criteria: step-through with 2 alternatives) | 2026-08-10 |
Prior Authorization Required for Many Added/Changed Products
Obtain prior authorization as specified for added/changed products on the pharmacy or medical benefit. Examples requiring PA: Yuviwel injection, Contepo injection (pharmacy; may be available without PA under medical benefit), Zycubo vial, Orladeyo pellet packet, Spinraza high‑dose vial (medical benefit), Lymphir injection (medical benefit), Aqvesme tablet, Sdamlo powder for oral solution, Cardamyst nasal spray. Some products added to the pharmacy benefit may also be available under the medical benefit without PA (see Contepo). Follow the PA requirements and effective dates as listed.
- Examples of products newly requiring PA: Yuviwel, Contepo (pharmacy PA; medical benefit may be without PA), Zycubo, Orladeyo, Spinraza HD (medical benefit), Lymphir (medical benefit), Aqvesme, Sdamlo, Cardamyst.
- Follow the stated effective dates (most PA additions effective 2026-08-10; GLP‑1 coverage changes effective 2026-07-01).
New Quantity Limits — Adhere to Limits When Requesting/Dispensing
Adhere to newly specified quantity limits. The following limits apply and must be followed when requesting or dispensing: Linzess — 30 capsules per 30 days; Myqorzo — 30 tablets per 30 days; Cardamyst 70 mg nasal spray — 2 units (140 mg total) per 30 days; Yuviwel injection — 2 vials per 7 days; Aqvesme tablet — 60 tablets per 30 days.
- Linzess: 30 capsules / 30 days
- Myqorzo: 30 tablets / 30 days
- Cardamyst: 2 units (140 mg total) / 30 days
- Yuviwel: 2 vials / 7 days
- Aqvesme: 60 tablets / 30 days
Antibiotics and related criteria updates (Effective 2026-08-10)
Antibiotics and Other Additions/Criteria Changes (Effective 2026-08-10)
Multiple pharmacy benefit additions and criteria modifications with PA and quantity limits.
Diagnosis and Step‑Through Documentation Requirements for cUTI, Contepo, and Fetroja
cUTI criteria now accept pyelonephritis as an eligible diagnosis and add cefotaxime and tobramycin as acceptable treatment alternatives. Contepo and Fetroja have step‑through/trial expectations: Contepo (pharmacy) will require prior authorization and a step‑through trial with two alternatives; Contepo may be available under the medical benefit without PA. Fetroja added to HABP/VABP for ABC infections and will require a trial with at least two alternatives and Xacduro. Use these expanded diagnostic allowances and step‑through lists when documenting PA requests.
- cUTI: pyelonephritis accepted as a diagnosis; cefotaxime and tobramycin listed as acceptable alternatives.
- Contepo: PA required, criteria require step‑through with two alternatives; may be available under medical benefit without PA.
- Fetroja: added for ABC HABP/VABP; requires trial with ≥2 alternatives and Xacduro.
Various therapeutic class updates (Effective 2026-08-10)
Various Therapeutic Class Updates (Effective 2026-08-10)
A series of criteria updates, additions, and step-through requirements across many drug classes.
Step‑Therapy Sequencing and Required Trials (selected examples)
Notable step‑therapy and sequencing requirements to apply before PA approval: Myqorzo requires prior trial of Camzyos; Linzess adults (≥18) require trial of lubiprostone before approval (members <18 no step‑through required); Kanjinti has been added as a step‑through option for other trastuzumab agents; Aqvesme for transfusion‑dependent beta‑thalassemia requires step‑through with Reblozyl or an attestation that Aqvesme will not be used in combination with Reblozyl. Zepbound (tirzepatide) requires step‑through with Wegovy injection for moderate to severe OSA.
- Myqorzo: step‑through with Camzyos required.
- Linzess (adults ≥18): step‑through with lubiprostone required; members <18 do not require this step.
- Kanjinti: added as step‑through for trastuzumab agents.
- Aqvesme (transfusion‑dependent beta‑thalassemia): step‑through with Reblozyl or attestation required.
- Zepbound (tirzepatide): step‑through with Wegovy injection for moderate to severe OSA.
Pediatric / EPSDT and Other Documentation Expectations
Pediatric/EPSDT and other documentation requirements: Vyjuvek age indication expanded to include patients from birth to 6 months — document age accordingly; EPSDT members qualifying for GLP‑1s require clinical rationale if not using Wegovy and additional step‑throughs apply for ages 12–21 (phentermine plus Wegovy when new to therapy). Benlysta lupus nephritis criteria now list cyclophosphamide as an induction option as part of triple therapy — document induction regimen choices. Immunotherapy criteria have been aligned to package inserts and NCCN guidance, including updated biomarker and age requirements — provide documentation consistent with the applicable package insert or NCCN guidance when requesting immunotherapy approvals.
- Vyjuvek: expanded to birth to 6 months — include age in documentation.
- EPSDT/GLP‑1: provide clinical rationale for not using Wegovy for EPSDT‑eligible members; ages 12–21 new to GLP‑1 also require phentermine step‑through.
- Benlysta (lupus nephritis): document induction regimen if using cyclophosphamide as part of triple therapy.
- Immunotherapies: align biomarker/age documentation with package inserts and NCCN guidance.
Action required — provider checklist
Priority Provider Actions — PAs, Step‑Therapy, Documentation, Quantity Limits
Immediate provider actions: obtain new prior authorizations where required (examples: Yuviwel, Contepo, Zycubo, Orladeyo, Spinraza HD, Lymphir, Aqvesme, Sdamlo, Cardamyst), adhere to new step‑therapy rules (examples: Zepbound → Wegovy step‑through; ustekinumab non‑preferred agents require trial of preferred biosimilars; Myqorzo requires Camzyos trial), ensure EPSDT/pediatric documentation and diabetes comorbidity documentation for GLP‑1s (provide EPSDT rationale and new diabetic medication prescription when applicable), and apply new quantity limits (e.g., Linzess 30/30, Myqorzo 30/30, Cardamyst 2 units/30 days, Yuviwel 2 vials/7 days, Aqvesme 60/30).
- Obtain PAs for newly added/changed products (see examples above).
- Follow step‑therapy sequencing (Zepbound → Wegovy; ustekinumab non‑preferred → trial preferred biosimilars; Myqorzo → Camzyos).
- Document EPSDT/pediatric rationale and diabetes comorbidity (new diabetic prescription) for GLP‑1s.
- Apply new quantity limits (Linzess 30/30; Myqorzo 30/30; Cardamyst 2 units/30 days; Yuviwel 2 vials/7 days; Aqvesme 60/30).
Definitions
Formulary: These drugs are included in the MassHealth drug list.
Prior Authorization (PA): Prior authorization is required. The prescriber must obtain PA for the drug. PA applies to both the brand-name and the FDA "A"-rated generic equivalent of listed product.
Brand Preferred (BP): Brand preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
Preferred Drug (PD): Preferred drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
Policy update changes
MassHealth will no longer cover medications used solely for weight loss (including GLP-1 agents and oral weight loss drugs); Wegovy retained as the sole non-diabetic GLP-1 preferred medication with limited covered indications (BMI >27 kg/m² with established CVD, MASH, BMI >30 kg/m² with moderate–severe OSA); Wegovy tablet covered for history of heart attack, stroke, symptomatic peripheral artery disease and for members <21; Zepbound (tirzepatide) designated non-preferred and requires step-through with Wegovy injection for moderate–severe OSA; EPSDT members need clinical rationale for not using Wegovy and ages 12–21 new to GLP-1 require step-through with phentermine; patients with diabetes/prediabetes must have a new written prescription for appropriate diabetic medication; existing PAs remain fillable through 2026-06-30.
Preferred ustekinumab biosimilars updated: Starjemza (ustekinumab-hmny) and unbranded ustekinumab-aekn designated preferred and interchangeable; Imuldosa (ustekinumab-srlf), Pyzchiva, and Steqeyma will no longer be preferred and will require trial of all preferred biosimilars; Imuldosa requires a new prescription and cannot be automatically substituted.
Multiple brand-name medications moved to non-preferred status requiring trial of generics (examples: Condolyx 0.5% gel → Podofilox 0.5% gel; Rowasa enema → mesalamine enema) to comply with UPPL.
Numerous pharmacy benefit additions with prior authorization and quantity limits (examples: Yuviwel injection added to pharmacy benefit with PA and quantity limit 2 vials per 7 days and step-through trial of Voxzogo; Contepo injection added to pharmacy benefit with PA and available without PA under medical benefit; Zycubo vial, Orladeyo pellet packet, Spinraza high-dose vial, Lymphir injection added with PA; Sdamlo oral solution and Cardamyst nasal spray added with PA and Cardamyst quantity limit 2 units/30 days; Myqorzo added with PA and quantity limit 30 tablets/30 days; Linzess remains with PA and now quantity limit 30 capsules/30 days; Amitiza (lubiprostone) will no longer require PA; Aqvesme added with PA and quantity limit 60 tablets/30 days with step-through/Reblozyl attestation for transfusion-dependent beta-thalassemia).
Antibiotics and infectious disease criteria updated: Zerbaxa pediatric indication expanded for cIAI and cUTI; doripenem removed as a step-through due to discontinuation; cUTI criteria expanded to include pyelonephritis and added cefotaxime and tobramycin as alternatives; age requirements for Recarbio and Avycaz in HABP/VABP updated (now FDA approved from birth to 18 years); Fetroja added to HABP/VABP ABC criteria with required trial of ≥2 alternatives and Xacduro; age restriction removed from Sivextro in SSTI/non-MRSA/non-VRE and VRE infections.
Wide-ranging clinical criteria updates across therapeutic areas including oncology immunotherapies (expanded and aligned indications for durvalumab, cemiplimab, pembrolizumab/Keytruda Qlex combinations, nivolumab, Tecentriq Hybreza, ipilimumab/Yervoy), lupus agents (Benlysta, Saphnelo, Lupkynis criteria refinements and step-throughs), prostate cancer agents (Akeega with prednisone for BRCA2-mutated mCSPC; Nubeqa monotherapy added with step-through requirement and confirmation of GnRH use or orchiectomy), pulmonary hypertension (Winrevair LVEF/WHO class updates), and other specialty updates.
Additional miscellaneous therapeutic updates effective 8/10/2026: Lybalvi criteria updated re: opioid treatment/withdrawal; Sdamlo requires step-through with Katerzia and Norliqva; Kanjinti added as a step-through for trastuzumab agents; Vyjuvek expanded to patients birth to 6 months; Santyl clarified for use with surgery/debridement; other clarifications and step-throughs across classes.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.