Understanding MassHealth Prescription Coverage and Benefits

MassHealth covers a wide range of prescription medications, including those for chronic conditions like diabetes, high blood pressure, and asthma.

MassHealth members have access to a network of over 70,000 pharmacies across the state, making it convenient to fill prescriptions.

MassHealth covers certain prescription medications for children, such as those for attention deficit hyperactivity disorder (ADHD) and asthma, at no cost to the family.

MassHealth also offers a program called Rx for MassHealth Adults, which covers certain medications for adults with chronic conditions, such as diabetes and high blood pressure.

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To get a MassHealth prescription, you'll need to go through a process that involves prior authorization. This is a requirement for certain medications, including Lunsumio (mosunetuzumab-axgb), which needs prior authorization information.

Mass General Brigham Health Plan, which includes Mass General Brigham Health Plan, Inc. and Mass General Brigham Health Insurance Company, handles prior authorization for MassHealth prescriptions. They have a system in place to review and approve or deny requests for these medications.

When Mass General Brigham Health Plan reviews your prescription, they may request prior authorization information for certain medications, such as Lunsumio (mosunetuzumab-axgb).

Mass General Brigham Health Plan includes both Mass General Brigham Health Plan, Inc. and Mass General Brigham Health Insurance Company.

To obtain prior authorization, you may need to provide additional information to support your treatment plan.

If you're a provider outside of the MGB ACO network, you can submit requests online through the online authorization submission form.

You can also reach out by phone at 800-711-4555 or fax your request to 844-403-1029.

To access the MassHealth Prior Authorization Form, simply click on the link provided.

Check the top of the criteria document for additional information about program details, benefit designation, and contact information.

The online authorization submission form is a convenient option for getting your requests processed quickly.

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To find out if a medication is covered, you can search the MassHealth Drug List or the online drug formulary. This will tell you if the medication requires prior authorization or is listed on the MassHealth formulary.

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Medications that require prior authorization can be submitted through Optum Rx for non-specialty medications, or Specialty Fusion for specialty medications. You can find the contact information for these companies on the MassHealth website.

For most members, pharmacy copayments are $1 for certain covered generic drugs, $3.65 for certain over-the-counter (OTC) drugs and covered generic and brand-name drugs, and $3.65 for both first-time prescriptions and refills of these drugs.

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If you're taking medications through your medical benefit, you'll need to get prior authorization for most of them. This is a process that ensures you're getting the right treatment for your condition.

Most medications covered on the medical benefit require prior authorization through Specialty Fusion. You can find a list of authorized medications on their website.

Specialty medications, like Epkinly (epcoritamab-bysp), Qalsody (tofersen), and Selarsdi (ustekinumab-aekn vial), also need prior authorization through Specialty Fusion.

To find out if a medication requires prior authorization, you can search the MassHealth Drug List. If you have any questions, you can call provider services at 855-444-4647.

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Specialty medications are required to be filled through a contracted specialty pharmacy after the first fill. To see if a medication is specialty, view the Specialty Pharmacy Drug List.

Some medications are only covered for off-label or non-FDA approved indications, which means they're used for a purpose not explicitly approved by the FDA. This can be a complex process, so it's essential to understand the specific requirements for each medication.

Asparlas (calaspargase pegol-mknl) and Danyelza (naxitamab-gqgk) are examples of medications that may be used for off-label indications. It's crucial to consult with a healthcare professional to determine the best course of treatment.

Plan Exclusions apply to certain medications, which means they're not covered under the plan. Berinert (c1 esterase inhibitor) is one such medication that may be excluded from coverage.

Avsola (infliximab-axxq) and Ruxience (rituximab-pvvr) are medical specialty and dual benefit drugs, which may have different coverage requirements than other medications. It's essential to review the plan's specific policies to understand the coverage details.

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If you're looking to fill your prescriptions, you're in luck because you can go to thousands of pharmacies, including Big Y, CVS, Rite Aid, Walgreens, Walmart, Price Chopper, Shaw’s/Star Market, and Stop & Shop.

To find out if a medication requires prior authorization or if it's listed on the MassHealth formulary, you can search the MassHealth Drug List.

You can submit prior authorizations for non-specialty medications to Optum Rx, and for specialty medications, you'll need to submit them to Specialty Fusion.

If you're unsure about the MassHealth formulary or prior authorization requirements, you can call provider services at 855-444-4647 for more information.

Some medications, like Epkinly (epcoritamab-bysp), Qalsody (tofersen), and Selarsdi (ustekinumab-aekn vial), require prior authorization.

You can find the specific prior authorization requirements for these medications by searching the MassHealth Drug List.

To get started with Fallon 365 Care, you'll need to qualify for MassHealth and live in one of the cities or towns in our service area.

There's no cost to join Fallon 365 Care, making it a great option for those who qualify.

Here are some pharmacies where you can fill your prescriptions: