Medical-Benefit Prior Authorization Required

Prior authorization is required for the listed agents when billed under the medical benefit (MassHealth UPPL).

Transition-of-Care: Current Therapy Review

Authorization may be reviewed on a case-by-case basis for members who are new to the plan and currently receiving the requested medication; this does not apply when the product was obtained as samples or through a manufacturer's patient assistance program.

• Provider should document current therapy and source of medication (exclude samples or manufacturer assistance supplies).
• Case-by-case review may permit continuation of existing, stable therapy consistent with FDA-approved indications.

Reauthorization and Continuation Requirements

Initial approvals and reauthorizations are for 6 months; reauthorization requires physician attestation of a positive response for all agents except Arzerra. For Arzerra, clinical rationale is required to continue therapy beyond the FDA‑approved duration.

• Include physician attestation documenting positive clinical response for reauthorization requests (non-Arzerra agents).
• For Arzerra, submit clinical rationale supporting treatment beyond the FDA‑approved duration when requesting continuation.

Policy Updates and Prior Authorization Note

Policy changes, additions, or new-agent criteria are subject to prior review by the Pharmacy & Therapeutics (P&T) committee and any applicable prior authorization requirements will be reflected in the review history.

• Providers should follow the most recent criteria as reflected in the policy review history when submitting prior authorization requests.
• New agents or criteria added after P&T review will require applicable prior authorization consistent with the updated policy.