Prior Authorizations

Here is our current prior authorization (coverage review) process for six select Medical Drug policies:

• Check the Massachusetts Medicaid and Qualified Health Plan Policy Topics and Covered HCPCS Drug Code List to see if a prior authorization is required for the medication, and associated J-code, you are requesting.
• If you believe it is medically necessary for a member to take a medication that is not covered by our medical benefit program, you may submit a coverage review request via:
  • Fax by submitting the appropriate form below to (866) 539-7185
  • Phone by contacting 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members.
• As always, please view our Medical Drug Policies before submitting your coverage review requests.

Here is our current prior authorization (coverage review) process for six select Medical Drug policies:

• Check the Massachusetts Medicaid and Qualified Health Plan Policy Topics and Covered HCPCS Drug Code List to see if a prior authorization is required for the medication, and associated J-code, you are requesting.
• If you believe it is medically necessary for a member to take a medication that is not covered by our medical benefit program, you may submit a coverage review request via:
  • Fax by submitting the appropriate form below to (866) 539-7185
  • Phone by contacting 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members.
• As always, please view our Medical Drug Policies before submitting your coverage review requests.

• • Asthma
  • Compliment Inhibitors
  • Erythropoiesis Stimulating Agents
  • Filgrastim
  • Infliximab
  • Rituximab
  • Massachusetts Medicaid and Qualified Health Plan Policy Topics and Covered HCPCS Drug Code List

Other Drug Exceptions

Use the forms below to request a prior authorization for a newly marketed drug, a brand-name drug, or for quantity limit exceptions.

• Chemotherapy and Supportive Care Prior Authorization Request Form
• Hepatitis C Prior Authorization Form
• Standard Medication Prior Authorization Form
• Synagis Prior Authorization Form

Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

Vaccines are covered under both Medicare Part B and Medicare Part D depending on the circumstances. In order to facilitate appropriate coverage and reporting of vaccines for Medicare enrollees in compliance with Medicare rules and regulations our Senior Care Options vaccine coverage is administered as follows:

Part B Vaccines:

• Pneumococcal
• Influenza
• Hepatitis B for Moderate or High Risk Individuals
• Vaccines used for treatment

• Any vaccine not listed above, which is prescribed for preventive purposes (i.e. Zostavax)
• A list of covered Part D vaccines is provided in the Plan formulary

• Pharmacy administration (Preferred Method) – Member obtains vaccine at a network pharmacy where it is administered by a pharmacist.
• Provider administration of vaccine purchased at pharmacy (Alternative Method 1) – Physician supplies the member with a prescription for the vaccine. Member picks up the prescription from the pharmacy and brings back to the provider office for administration.
• Provider administration with the vaccine supplied by the provider (Alternative Method 2) – Provider will need to use the reimbursement form to bill for Part D vaccines that are supplied and administered in office.