Mass General Brigham Health Plan Prior Authorization Lookup
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Latest Mass General Brigham Health Plan prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Krintafel (tafenoquine) prior authorization for P. vivax relapse preventionThis policy governs prior authorization requirements for Krintafel (tafenoquine) under the Mass General Brigham Health Plan pharmacy benefit for commercial/exchange members, specifying eligibility, testing, and quantity/duration limits.All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Medical Necessity Guidelines — Inpatient Surgical CareCriteria and prior authorization requirements Mass General Brigham Health Plan uses to determine medical necessity for elective inpatient surgical care across plan types, including Medicare Advantage, ACO, One Care/SCO, and Commercial/Qualified Health Plans.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Continuation of Therapy — Calcipotriene and Calcipotriene/Betamethasone Topical ProductsDefines prior authorization and reauthorization requirements for pharmacy benefit coverage of calcipotriene (vitamin D analogue) topical products and calcipotriene/betamethasone combination products for treatment of plaque psoriasis for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Continuation of Therapy — Elahere (mirvetuximab soravtansine-gynx)Policy governs prior-authorization and continuation/reauthorization criteria for medical-benefit use of Elahere for members (MassHealth UPPL) continuing therapy when new to the plan or requesting ongoing treatment.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Continuation of Therapy — Imiquimod AgentsThis policy governs prior-authorization and continuation-of-therapy rules for imiquimod topical products (including 3.75% and 5% strengths) under the Mass General Brigham Health Plan pharmacy benefit; it affects Commercial/Exchange members and applies to requests for ongoing treatment and reauthorization.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Continuation of Therapy — Spinraza (nusinersen) for Spinal Muscular AtrophyDefines prior authorization, continuation (reauthorization) criteria, and approval durations for Spinraza (nusinersen) under the Mass General Brigham Health Plan medical benefit, primarily for MassHealth UPPL members.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Continuation of Therapy — Tasimelteon (generic Hetlioz)Rules for prior authorization, quantity limits, and continuation (reauthorization) for tasimelteon capsules under the Mass General Brigham Health Plan pharmacy benefit, applying to Commercial/Exchange members.All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Datroway (datopotamab deruxtecan-dlnk) and related breast cancer therapies — Medical benefit prior authorization criteriaMedical benefit prior authorization criteria for Datroway and several HER2-directed and other breast cancer therapies for Mass General Brigham Health Plan (MassHealth UPPL). Applies to prescribers and oncology providers requesting authorization for these agents.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Initial Step-Therapy Requirements — Glaucoma AgentsDefines initial step-therapy sequencing, prior-authorization triggers, and coverage rules for specified glaucoma drugs under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Initial Step-Therapy Requirements — Ophthalmic SteroidsDefines pharmacy benefit step-therapy rules for ophthalmic corticosteroid products for Mass General Brigham Health Plan commercial/exchange members; governs point-of-sale adjudication and prior authorization triggers.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Initial Step-Therapy Requirements — Proton Pump Inhibitors (PPIs)Defines initial pharmacy benefit step-therapy rules, first- and second-line PPI agents, quantity limits, approval duration, and prior-authorization conditions for Mass General Brigham Health Plan commercial/exchange members.All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Long-Acting Colony Stimulating Factors (pegfilgrastim and efbemalenograstim biosimilars)Policy governing prior authorization and pharmacy benefit coverage of FDA-approved long-acting granulocyte colony-stimulating factor products for members of Mass General Brigham Health Plan.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01Lymphoma and Leukemia Agents (Arzerra, Gazyva, Zynlonta) - Medical-Benefit Prior AuthorizationMedical-benefit prior authorization policy for specified lymphoma and leukemia agents (Arzerra/ofatumumab vial, Gazyva/obinutuzumab, Zynlonta/loncastuximab) describing indications, authorization criteria, continuation and limitation rules for Mass General Brigham Health Plan members (MassHealth UPPL).All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01MassHealth Pharmacy and Medical Benefit Updates (Effective 7/1/2026)Governs MassHealth pharmacy and selected medical benefit coverage changes effective July 1, 2026, including formulary status, prior authorization, step therapy, quantity limits, and preferred product updates affecting prescribers, pharmacists, and plan administrators.All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01MassHealth pharmacy formulary and prior authorization updates (multiple drugs and classes)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.All Mass General Brigham Health Plan updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Medical Necessity Guidelines Prostheses - Upper LimbGuidelines governing medical necessity, prior authorization, coverage, exclusions, and coding for upper limb prostheses and related components for Mass General Brigham Health Plan members across product lines.All Mass General Brigham Health Plan updates
- Prior AuthClinical/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
- Prior AuthReimbursement/Payment PolicyEff. 2026-07-01NovoSeven RT (coagulation factor VIIa [recombinant]) coverage under the pharmacy benefitDefines Mass General Brigham Health Plan pharmacy benefit coverage and prior authorization requirements for NovoSeven RT (recombinant factor VIIa) for specified bleeding disorders and compendial uses; applies to Commercial/Exchange pharmacy benefit members and specialty pharmacy processes.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/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
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Omalizumab (Xolair) and related biologics coverageClinical prior authorization guidelines for Xolair (omalizumab) and summary coverage rules for several other allergy / asthma biologics under the Mass General Brigham Health Plan medical benefit. Applies to providers requesting authorization for covered indications and members under the listed plan programs.All Mass General Brigham Health Plan updates
- Prior AuthReimbursement/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
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Prior authorization criteria for select pharmacy drugs (EPSDT and gender-affirming care)Defines prior authorization review criteria for drugs used in gender-affirming care and for members under 21 (EPSDT), including a list of specific products with drug-specific criteria and authorization limits. Affects providers requesting PA for these pharmacy benefit drugs under Mass General Brigham Health Plan.All Mass General Brigham Health Plan updates
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Tool Description
Search Mass General Brigham Health Planprior 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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