CurrentMass General Brigham Health PlanPolicy N/A

Medical Specialty Medications — Commercial/Exchange Prior Authorization List

A commercial/exchange prior authorization listing of medical specialty medications (HCPCS/J-codes and Q-codes) indicating program flags (HCT, Enhanced DW Program, PD-1 Weight-Based Dosing, IVIG Dose Optimization) effective 05/01/2026 for Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Specialty Medications — Commercial/Exchange Prior Authorization List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date05/01/2026

Next Review DateN/A

Key ActionPrior authorization is required for specialty medications listed on the Commercial/Exchange prior authorization list; submit the applicable HCPCS/J- or Q-code and program flags when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

05/01/2026effective date shown on list

20+medication entries (partial extract)

flagsprogram flags shown

multipleIVIG dose optimization entries

Coverage / Criteria Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medications Requiring Prior Authorization (Commercial/Exchange list)

The following medications are on the Mass General Brigham Health Plan Commercial/Exchange Prior Authorization list effective 05/01/2026. Covered when the plan's prior authorization requirements are met for the listed HCPCS/J-codes.

Medications Requiring Prior Authorization: This list includes the Medical Specialty Medications shown in the source extract (commercial/exchange prior authorization list effective 05/01/2026).

Representative codes from the extract include (non‑exhaustive): J3380 (vedolizumab), Q5149 (aflibercept-abzv / Enzeevu), J9321 (epcoritamab-bysp / Epkinly), Q5151 (eculizumab-aagh / Epysqli), J9055 (cetuximab / Erbitux), J7323 (hyaluronan or derivative / Euflexxa), J3111 (romosozumab-aqqg / Evenity), J1951 (leuprolide acetate depot / Fensolvi), J1744 (icatibant / Firazyr), J9155 (degarelix / Firmagon), J1572 (intravenous immune globulin / Flebogamma), J9331 (sirolimus-albumin-bound / Fyarro), Q5130 (pegfilgrastim-pbbk / Fylnetra), J9210 (emapalumab-lzsg / Gamifant), J1569 (intravenous immune globulin / Gammagard Liquid), J1566 (immune globulin / Gammagard S/D), J1561 (intravenous immune globulin / Gammaked), J1558 (subcutaneous immune globulin), J0218 (olipudase alfa-rpcp / Xenpozyme), J0897 (denosumab / Xgeva), J2357 (omalizumab / Xolair), J3590 (denosumab-qbde / Xtrenbo; narsoplimab-wuug / Yartemlea), J9228 (ipilimumab / Yervoy), Q5154 (aflibercept-jbvfv / Yesafili), Q2041 (axicabtagene ciloleucel / Yescarta), Q5100 (ustekinumab-kfce / Yesintek IV), J1553 (intravenous immune globulin / Yimmugo), J9352 (trabectedin / Yondelis), J9223 (lurbinectedin / Zepzelca), J9276 (zanidatamab-hrii / Ziihera), J3304 (triamcinolone acetonide / Zilretta), Q5118 (bevacizumab-bvzr / Zirabev), J3399 (onasemnogene abeparvovec‑xioi / Zolgensma), J9282 (mitomycin / Zusduri), J9359 (loncastuximab tesirine‑lpyl / Zynlonta), J3393 (betibeglogene autotemcel / Zynteglo), J9345 (retifanlimab‑dlwr / Zynyz).

The extract provided for this section is an itemized code list indicating membership on the Commercial/Exchange prior authorization list effective 05/01/2026. It does not include the plan's full medical necessity criteria, clinical indication descriptions, quantity limits, step therapy sequences, or procedural requirements that may apply with prior authorization.

This excerpt is a code-level list with program flags (e.g., HCT, Enhanced DW Program, PD‑1 weight‑based dosing, IVIG dose optimization) captured in the source. It is not a standalone clinical policy and does not contain explicit medical necessity criteria, approval conditions, or documentation checklists required to adjudicate a prior authorization request.

Clinical indications, explicit exclusions, and detailed utilization management rules are not present in this extract. Refer to the Mass General Brigham Health Plan prior authorization policy documents and clinical criteria for full coverage determination and any exclusionary language.

No 'not medically necessary' language appears in the provided chunks. Absence of such language in this extract does not imply the plan has no noncoverage determinations—those determinations are defined in the full policy and clinical criteria documents.

HCPCS / J- and Q-Code Listing

Listed HCPCS/Codes (partial extract)mixed

Q2055	Abecma; idecabtagene vicleucel
J9264	Abraxane; paclitaxel albumin-bound
J3262	Actemra IV; tocilizumab
J0801	Acthar_HP; corticotropin
J0791	Adakveo; crizanlizumab-tmca
J9042	Adcetris; brentuximab vedotin
J9029	Adstiladrin; nadofaragene firadenovec-vncg
J7171	Adzynma; ADAMTS13, recombinant-krhn
Q5150	Ahzantive; aflibercept-mrbb
J1454	Akynzeo IV; fosnetupitant/palonosetron

1–10 of 95

1/10

Specialty medication codes (excerpt)HCPCS

J3380	vedolizumab
Q5149	aflibercept-abzv (Enzeevu)
J9321	epcoritamab-bysp (Epkinly)
Q5151	eculizumab-aagh (Epysqli)
J9055	cetuximab (Erbitux)
J7323	hyaluronan or derivative (Euflexxa)
J3111	romosozumab-aqqg (Evenity)

Specialty medication codes (continued)HCPCS

J1305	evinacumab-dgnb (Evkeeza)
J3590	depemokimab-ulaa / multiple J3590 branded entries
J1428	eteplirsen (Exondys-51)
J0178	aflibercept (Eylea)
J0177	aflibercept (Eylea HD)
J0180	agalsidase beta (Fabrazyme)
J0517	benralizumab (Fasenra)
J1951	leuprolide acetate (for depot suspension) (Fensolvi)
J1744	icatibant (Firazyr)
J9155	degarelix (Firmagon)

1–10 of 85

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Partial list of specialty J-codes (chunk 36)HCPCS

J3263	toripalimab-tpzi
J2778	ranibizumab (Lucentis)
J0221	alglucosidase alfa (Lumizyme)
J9350	mosunetuzumab-axgb (Lunsumio)
J9217	leuprolide acetate (Lupron Depot)
J1950	leuprolide acetate (Lupron Depot-Ped)

Partial list of specialty J-/Q-codes (chunks 37-38)HCPCS

J3398	voretigene neparvovec-rzyl (Luxturna)
J3394	lovotibeglogene autotemcel (Lyfgenia)
J9161	denileukin diftitox-cxdl (Lymphir)
J9601	linvoseltamab (Lynozyfic)
J9353	margetuximab-cmkb (Margenza)
J3397	vestronidase alfa-vjbk (Mepsevii)
J0888	methoxy polyethylene glycol-epoetin beta (Mircera)
J9349	tafasitamab-cxix (Monjuvi)

Extended specialty J-/Q-codes (chunks 40-55)HCPCS

J1458	galsulfase (Naglazyme)
J1442	filgrastim (Neupogen)
J0219	avalglucosidase alfa-ngpt (Nexviazyme)
J9038	axatilimab-csfr (Niktimvo)
Q5110	filgrastim-aafi (Nivestym)
J2802	romiplostim (Nplate)
J2182	mepolizumab (Nucala)
J1809	fosdenopterin (Nulibry)
J2350	ocrelizumab (Ocrevus)
J1568	intravenous immune globulin (Octagam)

1–10 of 57

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Specialty drug HCPCS codes (excerpt)HCPCS

J9062	IVIG Dose Optimization *+ = N
J9021	Rylaze (asparaginase erwinia chrysanthemi recombinant-rywn); HCT=N; Enhanced DW Program=Y; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J3402	Ryoncil (remestemcel-L-rknd); HCT=Y; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J9333	Rystiggo (rozanolixizumab-noli); HCT=Y; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J0870	Rytelo (imetelstat); HCT=N; Enhanced DW Program=Y; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J9361	Ryzneuta (efbemalenograstim alfa-vuxw); HCT=N; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J0491	Saphnelo (anifrolumab-fnia); HCT=N; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J9227	Sarclisa (isatuximab-irfc); HCT=N; Enhanced DW Program=Y; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
J7352	Scenesse (afamelanotide); HCT=N; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N
Q9998	Selarsdi IV (ustekinumab-aekn); HCT=N; Enhanced DW Program=N; PD-1 Wt Based Dosing+=N; IVIG Dose Optimization+=N

1–10 of 21

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Specialty HCPCS/J-codes (partial)HCPCS

J1558	subcutaneous immune globulin
J0218	Xenpozyme / olipudase alfa-rpcp
J0897	Xgeva / denosumab
J2357	Xolair / omalizumab
J3590	Xtrenbo / denosumab-qbde; also Yartemlea / narsoplimab-wuug (multiple generics mapped to J3590 in this extract)
J9228	Yervoy / ipilimumab

Specialty HCPCS/J/Q-codes (partial)HCPCS

Q5154	Yesafili / aflibercept-jbvfv
Q2041	Yescarta / axicabtagene ciloleucel
Q5100	Yesintek IV / ustekinumab-kfce
J1553	Yimmugo / intravenous immune globulin
J9352	Yondelis / trabectedin
J9223	Zepzelca / lurbinectedin

Specialty HCPCS/J/Q-codes (continued)HCPCS

Q5120	Ziextenzo / pegfilgrastim-bmez
J9276	Ziihera / zanidatamab-hrii
J3304	Zilretta / triamcinolone acetonide
Q5118	Zirabev / bevacizumab-bvzr
J3399	Zolgensma / onasemnogene abeparvovac-xioi
J9282	Zusduri / mitomycin
J9359	Zynlonta / loncastuximab tesirine-lpyl
J3393	Zynteglo / betibeglogene autotemcel
J9345	Zynyz / retifanlimab-dlwr

Thresholds / Numeric Criteria

Numeric clinical thresholdsNo numeric clinical thresholds are present in this extract; the document lists HCPCS/J-/Q-codes with program flags only.

Implication for reviewersCoverage determination relies on code membership and program flags; numeric dose/age/lab thresholds are not provided here.

Next stepRefer to full policy sections or utilization management procedures for any clinical thresholds or detailed medical necessity criteria.

PD-1 Weight-Based Dosing Flag

PD-1 weight-based dosing flag presentSome entries include a 'PD-1 Wt Based Dosing *+ = Y' marker indicating weight-based dosing applies for that PD-1 inhibitor entry.

Example codeJ9271 (Keytruda) is marked 'PD-1 Wt Based Dosing *+ = Y' in the extract.

Documentation noteProviders should reference the PD-1 weight-based dosing flag when submitting authorization requests for affected agents.

Actions for Providers / Prior Authorization Impact

Prior Authorization

Prior Authorization Required (Commercial/Exchange)

Commercial/Exchange prior authorization list for Medical Specialty Medications effective 05/01/2026. Providers must obtain prior authorization for the specialty medications and HCPCS J- and Q-codes shown on this list before administration or billing.

This section is a prior authorization list (excerpt) — it identifies HCPCS J- and Q-codes and associated program flags.
Prior authorization is required (implied) for the medications and codes on this Commercial/Exchange list effective 05/01/2026.
The list shows each line item with: HCPCS (J- or Q-) code, brand/generic name, and program flags (HCT, Enhanced DW Program, PD-1 Weight‑Based Dosing, IVIG Dose Optimization).
Step therapy details are not provided in this excerpt; only program flags are shown (no step edits visible).

Prior Authorization

Prior Authorization Applies to Listed Specialty Medications

Prior authorization applies to the specialty medications listed by HCPCS J- and Q-code. When submitting a PA, include the HCPCS code, brand/generic name, and any program-flag related documentation required to support authorization.

Entries are listed with code and program flags to guide submission/documentation.
Required coding and program flag documentation should be included with the PA (e.g., HCT = Y/N, Enhanced DW Program = Y/N, PD-1 Weight‑Based Dosing = Y/N, IVIG Dose Optimization = Y/N).

Prior Authorization

Prior Authorization Required

Providers: check the prior authorization list before claim submission. If a medication's J- or Q-code appears on this list, obtain prior authorization per the Commercial/Exchange program rules effective 05/01/2026.

Provider action: Prior authorization list (excerpt) — obtain PA for listed codes.
Provider action: Not specified in this extract for any exceptions; follow standard PA submission process.

Prior Authorization

Prior Authorization List (excerpt)

The HCPCS J- and Q-codes shown in this excerpt are on the prior authorization list and subject to the authorization rules. Use the code and program-flag values from the list when preparing documentation.

List shows multiple J- and Q-codes (examples in document): J3380, J9321, Q5149, Q5151, J9055, J3111, J1305, J3590, J1428, J0178, J0221, J9350, J9217, J1950, J3398, J3394, J9161, J9601, J9353, J3397, J0587, J9062, J9021, J3402, J9333, J0870, J9361, J0491, J9227, J1961, J7321, J9226, J1627, J2779, J2781, J7325, J1558, J0218, J0897, J2357, J3590, J9228, Q5154, Q2041, Q5100, J1553, J9352, J9223, Q5120, J9276, J3304, Q5118, J3399, J9282, J9359, J3393, J9345.
Provider action: Prior authorization required (implied) for these codes.

Documentation Required

Required Coding and Program-Flag Documentation

When submitting prior authorization requests, include required coding and any program-flag related documentation (e.g., HCT status, Enhanced DW Program enrollment, PD-1 weight‑based dosing details, IVIG dose optimization indicators) to avoid delays or denials.

Required coding and program flag documentation (list): HCPCS J- or Q-code, brand/generic name, HCT = Y/N, Enhanced DW Program = Y/N, PD-1 Weight‑Based Dosing = Y/N, IVIG Dose Optimization = Y/N.
Submission details: entries are listed with code and program flags and these guide what documentation to include with the PA.

Abbreviations & Program Flags

HCT Flag (appearing alongside drugs)

HCT flag usageEntries include 'HCT *' next to HCPCS/J-/Q-codes indicating association with hematopoietic cell transplant programs for that product.

Examples of HCT = YQ2055 (Abecma), J1931 (Aldurazyme), J9321 (Epkinly), J931? (multiple entries in list) are shown with HCT * = Y in the extract.

Examples of HCT = NMany products (e.g., J9264 Abraxane, J0801 Acthar_HP) are listed with HCT * = N.

Enhanced DW Program Flag

Enhanced DW Program flagSome medication entries include 'Enhanced DW Program*' markers (Y/N) to denote participation in the plan's Enhanced DW Program.

Examples with Enhanced DW = YJ9264 (Abraxane), J3262 (Actemra IV), J9042 (Adcetris), J9331 (Fyarro) are shown with Enhanced DW Program* = Y in the extract.

Examples with Enhanced DW = NMany other entries are shown with Enhanced DW Program* = N; details of the program are not defined in this extract.

PD-1 Weight-Based Dosing Flag

PD-1 Wt Based Dosing indicatorCertain PD-1 inhibitor entries are marked 'PD-1 Wt Based Dosing *+', indicating dosing for that product is weight-based per the program flag.

ExampleJ9271 (Keytruda) is shown with PD-1 Wt Based Dosing *+ = Y; other PD-1/PD-L1 agents in the list show N or blank.

Definition statusThe extract does not include a formal definition of the flag; it functions as a program/dosing indicator on the code list.

IVIG Dose Optimization Flag

IVIG Dose Optimization flagIntravenous/subcutaneous immune globulin entries include an 'IVIG Dose Optimization *+' marker (Y/N) indicating whether IVIG dose optimization applies.

Examples marked YJ1572 (Flebogamma), J1569 (Gammagard Liquid), J1566 (Gammagard S/D), J1558 (subcutaneous immune globulin) are shown with IVIG Dose Optimization *+ = Y in the extract.

Examples marked NMany other non-IVIG products are marked IVIG Dose Optimization *+ = N.

HCT * (Y/N) Association

HCT * meaning on list'HCT *' indicates whether the code/product is associated with hematopoietic cell transplant programs (values shown as Y or N next to entries).

Examples HCT = YQ2055 (Abecma), J1931 (Aldurazyme), J9321 (Epkinly), J9210 (Gamifant), J3590 entries and others are marked HCT * = Y in the extract.

Examples HCT = NMany listed products (e.g., J9264 Abraxane, J0801 Acthar_HP) show HCT * = N.

IVIG Dose Optimization *+ (Y/N)

IVIG Dose Optimization *+ applicabilityThe '*+' IVIG Dose Optimization flag indicates whether the IVIG dose optimization program applies to the listed immune globulin product (Y = yes, N = no).

Examples with *+ = YJ1572 (Flebogamma), J1569 (Gammagard Liquid), J1566 (Gammagard S/D), J1553/J1552/J1558 entries show IVIG Dose Optimization *+ = Y for some formulations.

Examples with *+ = NNon-IVIG products in the list are shown with IVIG Dose Optimization *+ = N.

HCT Flag (relation to hematopoietic cell transplant)

HCT flag (list presentation)The HCT marker is presented alongside medication entries (HCT * = Y or N) to denote relation to hematopoietic cell transplant programs as shown in the list.

Representative entriesJ0221 (Lumizyme) and other gene/cell therapy products are shown with HCT flags in the extract.

Action for providersReference the HCT flag on the code line when preparing authorization documentation for transplant-related therapies.

Enhanced DW Program (entry flag)

Enhanced DW Program marker on entriesSome medications show an 'Enhanced DW Program*' marker (Y/N) next to the HCPCS/J-/Q-code indicating participation in that program.

ExamplesJ3263 (toripalimab-tpzi), J9331 (Fyarro), and others are shown with Enhanced DW Program* = Y in the extract.

Definition not includedThe extract does not define the Enhanced DW Program; details must be obtained from full plan materials.

PD-1 Wt Based Dosing (entry indicator)

PD-1 Wt Based Dosing indicator per entryEntries for PD-1 agents include a 'PD-1 Wt Based Dosing *+' marker showing whether weight-based dosing applies (Y/N) for that specific code line.

ExampleJ9271 (Keytruda) is explicitly shown with PD-1 Wt Based Dosing *+ = Y; other PD-1 entries show N.

Provider implicationInclude the PD-1 weight-based dosing flag when documenting dosing regimen for authorization requests of PD-1 inhibitors.

IVIG Dose Optimization (entry flag)

IVIG Dose Optimization flag on medication entriesMedication lines for immune globulins include 'IVIG Dose Optimization *+' markers indicating whether dose optimization applies to that product.

ExamplesJ1572 (Flebogamma), J1569 (Gammagard Liquid), J1558 (subcutaneous immune globulin) show IVIG Dose Optimization *+ = Y in the extract.

Usage noteProviders should verify IVIG optimization status from the code line when planning dosing and submitting authorizations for immune globulins.

Program Flags (general note)

Purpose of program flagsMarkers alongside each HCPCS/J-/Q-code indicate participation or applicability in administrative/utilization programs (examples: HCT *, Enhanced DW Program*, PD-1 Wt Based Dosing *+, IVIG Dose Optimization *+).

Displayed valuesFlags are presented as Y or N per entry to show whether the program applies to that specific product code line.

Provider actionWhen submitting prior authorization requests, reference the specific code line and its program flags as shown on the list; further program rules are located outside this extract.

OpenPayer

Medical Specialty Medications — Commercial/Exchange Prior Authorization List

Coverage / Criteria Summary

HCPCS / J- and Q-Code Listing

Actions for Providers / Prior Authorization Impact

Background and Policy Scope

Abbreviations & Program Flags