Blue Cross Blue Shield - Massachusetts Prior Authorization Lookup
- Blue Cross Blue Shield - Massachusetts coverage criteria
- All Blue Cross Blue Shield - Massachusetts policy updates
Latest Blue Cross Blue Shield - Massachusetts prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Non-Covered Drug List & Non-Coverary Formulary ExceptionDefines BCBSMA's non-covered drug list and the formulary-exception/prior authorization process for commercial pharmacy benefits; applies to commercial members covered under BCBSMA pharmacy plans and describes when non-formulary drugs may be authorized.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-07-01Authorization requirements by productDefines which outpatient and inpatient services require prior authorization or notification for Blue Cross Blue Shield of Massachusetts products and explains tools and procedures providers should use to verify and request authorizations.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Non-Covered Drug List & Non-Covered Formulary ExceptionThis pharmacy medical policy governs coverage and exception criteria for non-formulary or non-covered prescription drugs for BCBSMA commercial members and explains prior authorization and documentation requirements for providers requesting coverage exceptions.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Non-Covered Drug List & Non-Covered Formulary ExceptionDefines BCBSMA's non-covered drug list and the formulary exception/prior authorization process for commercial members with pharmacy benefits, including criteria for when non-formulary drugs may be authorized.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Formulary Exception / Non-covered Drug Prior AuthorizationDefines BCBSMA prior authorization and formulary exception criteria for coverage of non-formulary or non-covered prescription drugs for commercial members under the BCBSMA formulary; excludes Medicare Advantage. Affects prescribers requesting coverage exceptions and pharmacy operations processing prior authorizations.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-05-01Medical Benefit Prior Authorization Medication ListLists medications that require prior authorization when provided under the member's medical benefit in certain outpatient settings and identifies member types to which the requirement applies.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Neurology & Neurosurgery — Coverage Criteria and Policy Updates (Spine Fusion, Neuromodulation, DBS, MEG)Summarizes new and revised neurology/neurosurgery medical policies, investigational determinations, coding and prior authorization updates, and changes to InterQual applicability that affect BCBSMA providers and prior authorization processes.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-03-15Medical Benefit Prior Authorization Medication ListDefines which medications administered under the member's medical benefit in specified outpatient settings require prior authorization and which commercial product lines and member types the requirement applies to within Massachusetts.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-15Mupirocin step therapy and quantity limitsBCBSMA policy governing step therapy, formulary status, and quantity dosing rules for mupirocin products for commercial members; includes prior authorization and individual exception processes.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-15VEGF inhibitors and complement inhibitors for macular degeneration and diabetic eye diseaseClinical coverage and prior authorization requirements for VEGF inhibitors and complement inhibitors used to treat macular degeneration, diabetic eye disease, and related retinal conditions for BCBSMA commercial members.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Total Facet Arthroplasty (Lumbar) — Coverage CriteriaThis policy governs coverage and prior authorization requirements for total facet arthroplasty (posterior vertebral joint replacement) in the lumbar spine for Blue Cross Blue Shield of Massachusetts members across commercial and Medicare products.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-02-02Carelon (formerly AIM) Sleep Disorder Management CPT, HCPCS and Diagnoses CodesLists CPT and HCPCS codes in-scope for Carelon (formerly AIM) Sleep Disorder Management across Commercial and Medicare Advantage products and notes program-level prior authorization requirements and investigational status for select codes.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-02-01Carelon (formerly AIM) Advanced Imaging/Radiology CPT and HCPCS CodesLists CPT and HCPCS codes in-scope for Carelon Advanced Imaging/Radiology management programs for Commercial and Medicare Advantage products; indicates medical necessity is determined by Carelon clinical guidelines and notes prior authorization exceptions and radiotracer PA requirements.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-15Factor and Non-Factor Anti-Hemophilic Therapies (Hemophilia and Related Coagulation Disorders)Medical-benefit coverage policy for a broad set of coagulation factor and non-factor anti-hemophilic drugs (including factor VIII, IX, X, XIII, fibrinogen concentrate, anti-inhibitor complexes, TFPI antagonists, von Willebrand products, and related agents) for Commercial members (multiple product-specific indications described). Prior authorization is required. Policy does not apply to Medicare Advantage members.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-15Medical Benefit Prior Authorization Medication ListLists outpatient medications that require prior authorization when billed to a member's medical benefit for specified commercial lines in Massachusetts and describes applicable outpatient settings and member categories. Affects providers administering these medications and authorization staff for Blue Cross Blue Shield Massachusetts commercial plans.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-15VEGF inhibitors and complement inhibitors for macular degeneration and diabetic eye diseaseMedical necessity and prior authorization requirements for intravitreal VEGF inhibitors and complement inhibitors used to treat neovascular AMD, diabetic eye disease, retinal vein occlusion, geographic atrophy, and related ophthalmic indications for BCBSMA commercial plans.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Antihyperlipidemic agents prior authorization and quantity limitsDefines prior authorization, quantity limit, and clinical coverage criteria for specified antihyperlipidemic medications for BCBSMA commercial members (excludes Medicare Advantage). Applies to medications covered under pharmacy and/or medical benefits per formulary status.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Antihyperlipidemic agents prior authorization and quantity limitsGoverns prior authorization, quantity limit, and formulary requirements for select antihyperlipidemic medications for BCBSMA commercial members; affects providers submitting pharmacy or medical benefit requests.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-01-01Authorization or notification requirements by productGovernance of prior authorization and notification requirements across Blue Cross Blue Shield of Massachusetts product lines; applies to providers submitting requests and verifying member eligibility for a wide range of outpatient and inpatient services.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Formulary exception / non-covered drug coveragePolicy governing prior authorization and formulary exception criteria for non-formulary or non-covered prescription drugs for BCBSMA commercial members; describes documentation, approval criteria, and individual consideration process for prescribers requesting coverage.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01GLP-1 and GLP-1/GIP Agonist Drugs for Anti-Obesity Management and Other Non-Obesity ConditionsThis pharmacy medical policy governs prior authorization, coverage criteria, and approval durations for GLP-1 and GLP-1/GIP agonist medications for anti-obesity management (and other FDA-approved indications) for BCBSMA commercial members with formulary coverage. It does not apply to Medicare Advantage and excludes members on the BCBSMA Focused Formulary where these drugs are not covered.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01GLP-1 and GLP-1/GIP Agonist Drugs for Anti-Obesity Management and Other Non-Obesity ConditionsDefines prior authorization, coverage criteria, and continuation requirements for GLP-1 and GLP-1/GIP agonist medications for obesity and specified non-obesity indications for BCBSMA commercial formularies. Applies to providers requesting coverage for affected members under BCBSMA commercial plans.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Prior authorization and quantity limit requirements for antihyperlipidemic agentsGoverns prior authorization (PA) and quantity limit (QCD) requirements for specified antihyperlipidemic medications for BCBSMA commercial members; affects providers requesting coverage under pharmacy or medical benefits.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Quality Care Dosing (QCD) Guidelines List — drug-specific quantity and daily limitsLists per-period quantity (QCD) limits and maximum daily doses for many prescription medications and indicates prior authorization (PA), step therapy (ST), specialty (SP/SPO) flags, and non-covered status; applicable to providers and pharmacies dispensing to BCBS MA members.All Blue Cross Blue Shield - Massachusetts updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-01Liposuction for Lipedema and LymphedemaThis policy defines medical necessity, prior authorization, coding, and coverage criteria for lipectomy or liposuction to treat documented lipedema and lymphedema for Blue Cross Blue Shield - Massachusetts members.All Blue Cross Blue Shield - Massachusetts updates
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Tool Description
Search Blue Cross Blue Shield - Massachusettsprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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