Mass General Brigham Health Plan Coverage Criteria
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Latest Mass General Brigham Health Plan coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Imlygic (talimogene laherparepvec, T-VEC) medical necessityDefines medical necessity criteria, dosing, exclusions, and coding guidance for Imlygic (T-VEC) for treatment of unresectable melanoma lesions for Mass General Brigham Health Plan members across lines of business.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Positive Airway Pressure therapy for sleep disordered breathingDefines medical necessity, initial trial, and continued coverage criteria for CPAP/APAP and bi-level PAP devices and related supplies for adults and children with obstructive sleep apnea and other sleep-disordered breathing conditions.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Diclofenac sodium gel 3% (Solaraze) — Prior Authorization and Quantity LimitsDefines prior authorization, quantity limits, and coverage criteria for diclofenac sodium gel 3% under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Emrelis (telisotuzumab vedotin‑tllv) — Coverage CriteriaDefines prior authorization requirements and medical benefit coverage criteria for Emrelis (telisotuzumab vedotin-tllv) for adults with locally advanced or metastatic non‑squamous non‑small cell lung cancer with high c‑Met overexpression; applies to Mass General Brigham Health Plan medical benefit members including MassHealth UPPL.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Infliximab products (Avsola, Inflectra, Infliximab, Remicade, Renflexis) — FDA-Approved IndicationsThis policy governs prior authorization and coverage criteria for FDA‑approved and approvable compendial uses of infliximab products for Mass General Brigham Health Plan members, primarily under the pharmacy benefit and specialty pharmacy processes.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Initial Step-Therapy Requirements — ADHD Stimulants Step TherapyDefines initial step-therapy requirements, coverage criteria, and quantity limits for stimulant medications used to treat ADHD under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Medical Necessity Guidelines — Xofigo (radium Ra-223 dichloride)Medical necessity criteria and prior authorization requirements for use of Xofigo in members with metastatic castration-resistant prostate cancer and symptomatic bone metastases across Mass General Brigham Health Plan product lines.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Octreotide acetate injection (coverage for acromegaly and other indications)This document governs prior-authorization pharmacy benefit coverage criteria for octreotide acetate injection for Mass General Brigham Health Plan commercial/exchange members and specifies specialty pharmacy dispensing and indication-specific requirements.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Parathyroid hormone analogs (Bonsity, Teriparatide (Alvogen), Tymlos)Prior authorization policy governing pharmacy benefit coverage for parathyroid hormone analog injections (Bonsity, teriparatide [Alvogen], Tymlos) for Commercial/Exchange members; defines coverage criteria, continuation, limits, and specialty dispensing requirements.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Prophylactic Treatment of Migraines — Injectable CGRP Inhibitors (Aimovig, Emgality)Defines prior authorization, pharmacy benefit coverage, clinical criteria, and quantity limits for Aimovig (erenumab) and Emgality (galcanezumab) for migraine prevention and episodic cluster headache in adult commercial/exchange members.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Short Acting Colony Stimulating Factors (CSFs)Defines pharmacy benefit coverage, prior authorization requirements, and clinical criteria for short-acting CSF products for Mass General Brigham Health Plan members under the pharmacy benefit.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Spravato (esketamine) — Major Depressive Disorder / Treatment-Resistant Depression (medical-benefit prior authorization)This medical-benefit prior authorization policy governs coverage and clinical criteria for Spravato (esketamine) for adults with treatment-resistant depression or MDD with acute suicidal ideation/behavior for Mass General Brigham Health Plan (including MassHealth UPPL). It applies to providers requesting authorization under the plan's medical benefit.All Mass General Brigham Health Plan updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Weight Loss Medications: Contrave, Liraglutide (Saxenda), Wegovy (semaglutide) injection, Zepbound (tirzepatide)Pharmacy benefit prior authorization policy for weight management medications (Contrave, liraglutide/Saxenda, Wegovy/semaglutide, Zepbound/tirzepatide) including indications, coverage criteria, continuation, and limitations for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Daybue (trofinetide) oral solution and Daybue STIX coverage criteriaDefines prior authorization, coverage criteria, quantity limits, and specialty pharmacy requirements for Daybue (trofinetide) oral solution and Daybue STIX for commercial/exchange members age 2 and older.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Jascayd (nerandomilast) prior authorization for idiopathic pulmonary fibrosis and progressive pulmonary fibrosisDefines prior authorization, coverage criteria, and specialty pharmacy requirements for Jascayd (nerandomilast) for adults with idiopathic pulmonary fibrosis or progressive pulmonary fibrosis under the Mass General Brigham Health Plan commercial/exchange pharmacy benefit.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-11Medical Necessity Guidelines Itvisma (onasemnogene abeparvovec-brve)Medical necessity and prior authorization criteria for Itvisma (intrathecal onasemnogene abeparvovec-brve) for Mass General Brigham Health Plan members across plan lines, including Medicare Advantage, Mass General Brigham ACO, One Care/SCO, and Commercial plans.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Asthma and Allergy Injectables (Dupixent, Fasenra, Nucala, Xolair) - Coverage CriteriaPrior authorization requirements and clinical coverage criteria for Dupixent, Fasenra, Nucala, and Xolair under the commercial pharmacy benefit.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Bimzelx (bimekizumab-bkzx) prior authorization for indicated immune-mediated dermatologic and rheumatologic conditionsDefines pharmacy prior authorization, specialty pharmacy dispensing, clinical criteria, and reauthorization rules for Bimzelx for commercial/exchange members of Mass General Brigham Health Plan.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Cimzia (certolizumab pegol) prior authorization and coveragePrior authorization policy for Cimzia (certolizumab pegol) under the Commercial/Exchange pharmacy benefit at Mass General Brigham Health Plan; defines indications, coverage criteria, trial requirements, reauthorization, and quantity limits for affected members and providers.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Cosentyx (secukinumab) subcutaneous therapy — Clinical prior authorizationClinical prior authorization policy for Cosentyx (secukinumab) subcutaneous formulations under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members; includes indication-specific medical necessity criteria, continuation, limits, and specialty pharmacy requirement.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Enbrel (etanercept) prior authorization and coverage criteriaDefines prior authorization requirements, clinical criteria, limits, and reauthorization conditions for Enbrel (etanercept) under the Commercial/Exchange pharmacy benefit for Mass General Brigham Health Plan.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Fabhalta (iptacopan) — Coverage Criteria (PNH, IgAN, C3G)Policy governs prior authorization, coverage criteria, and quantity limits for Fabhalta (iptacopan) under the pharmacy benefit for Mass General Brigham Health Plan Commercial/Exchange members, including indications in PNH, IgAN, and C3G and specialty pharmacy dispensing requirements.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Forzinity (elamipretide) prior authorization for Barth syndromeDefines prior authorization, coverage criteria, and limits for Forzinity (elamipretide) for commercial/exchange pharmacy benefit members with Barth syndrome; applies to specialty pharmacy dispensing and prescribers in specified specialties.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01GC-C agonists and other prescription therapies for chronic constipation and IBS-C (linaclotide, lubiprostone, prucalopride, plecanatide)Pharmacy prior authorization policy governing coverage criteria, quantity limits, and continuation requirements for linaclotide (Linzess), lubiprostone (Amitiza), prucalopride (Motegrity), and plecanatide (Trulance) for Commercial/Exchange members.All Mass General Brigham Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Kevzara (sarilumab) prior authorizationPharmacy benefit prior authorization requirements for Kevzara (sarilumab) for commercial/exchange members, including diagnosis-specific coverage criteria, continuation criteria, and quantity limits; applies to specialty pharmacy dispensing.All Mass General Brigham Health Plan updates
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Tool Description
Search Mass General Brigham Health Plan coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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