ConnectorCare / Qualified Health Plans

Review clinical criteria and submit a prior authorization if necessary.

Here is our current prior authorization (coverage review) process:

  1. Check the formulary to see if prior authorization is required for a medication.
  2. If you believe that it is medically necessary for a member to take a medication that is not covered by our pharmacy program, you may submit a coverage review request online through one of these ePA portals: Surescripts, CoverMyMeds, or ExpressPAth.
  3. If you do not have access to an ePA system you can contact 877-417-1822 for MassHealth members or 877-417-0528 for Qualified Health Plan members. Or, you can submit the appropriate Standard Medication Prior Authorization Form:
  4. As always, please view our Pharmacy Policies before submitting your coverage review requests.

Medical Benefit Drug Review for select drugs

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

5. 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.

6. 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.

7. As always, please view our Medical Drug Policies before submitting your coverage review requests

For providers of our Senior Care Options members: Vaccines are covered under both Medicare Part B and Part D. Learn more about vaccine coverage.

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.

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

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