Policies

The policies below summarize BMC HealthNet Plan's medical coverage criteria and claims payment guidelines for specific services. You will also find policies related to administrative services.

The policies are used as a guide by the Plan to make clinical determinations regarding health care coverage and reimbursement. The Plan's policies undergo regular updates; check back often for the most up-to-date information. Providers are reminded that member eligibility is determined before medical coverage policies and reimbursement guidelines are applied to any claim. As a result, the Plan cannot guarantee payment when a member is ineligible or a non-covered benefit is rendered.

Type Title
Actigraphy Testing (Policy OCA 3.712), Effective 08/01/20
Administratively Necessary Days (Policy OCA 3.102), Effective 10/01/20
Ambulance and Transportation Services (Policy OCA 3.191), Effective 04/01/21 and Retired 04/30/21
Ambulance and Transportation Services (Policy OCA 3.191), Effective 05/01/21
Ambulance and Transportation Services (Policy OCA 3.191), Effective 06/01/20 and Retired 03/31/21
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy OCA 3.35), Effective 03/01/21
Ambulatory Cardiac Monitors (Excluding Holter Monitors) (Policy OCA 3.35), Effective 10/01/20 and Retired 02/28/21
Autism Spectrum Disorders Medical Diagnosis and Treatment (Policy OCA 3.724), Effective 08/01/20
Balloon Sinus Ostial Dilation (Policy OCA 3.706), Effective 08/01/20
Biofeedback in an Outpatient Setting to Treat Incontinence or Constipation (Policy OCA 3.969), Effective 10/01/20
Breast Reconstruction (Policy OCA 3.43), Effective 01/01/21
Breast Reduction Mammoplasty (Policy OCA 3.44), Effective 07/01/19 and Retired 12/31/20
Breast Reduction Surgery (Policy OCA 3.44), Effective 01/01/21
Cardiac Rehabilitation, Outpatient (Policy OCA 3.61), Effective 12/01/20 Used in Conjunction with InterQual Criteria Adopted 03/01/19
Car T-Cell Therapy to Treat Hematological Malignancies (Policy OCA 3.22), Effective 05/01/21
Car T-Cell Therapy with KYMRIAH or YESCARTA to Treat Hematological Malignancies (Policy OCA 3.22), Effective 12/01/20 and Retired 04/30/21
Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder (Policy OCA 3.82), Effective 01/01/21
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy OCA 3.573), Effective 02/01/20 and Retired 02/28/21 with InterQual Criteria Adopted 10/01/19
Chromosomal Microarray Analysis for Intellectual Disabilities and/or Multiple Congenital Anomalies (Policy OCA 3.573), Effective 03/01/21 with InterQual Criteria Adopted 10/01/19
Clinical Review Criteria (Policy OCA 3.201), Effective 01/01/21
Clinical Technology Evaluation (Policy OCA 3.13), Effective 01/01/21
Clinical Trials (Policy OCA 3.192), Effective 09/01/20
Cochlear Implants (Policy OCA 3.301), Effective 10/01/20
Complementary and Alternative Medicine, Including Acupuncture (Policy OCA 3.194), Effective 01/01/21
Contact Lens and Scleral Lens (Policy OCA 3.28), Effective 03/01/21
Contact Lens and Scleral Lens (Policy OCA 3.28), Effective 10/01/20 and Retired 02/28/21
Continuous Glucose Monitoring Systems, Artificial Pancreas Devices and Insulin Delivery Devices (Policy OCA 3.966), Effective 12/01/20
Cosmetic Reconstructive, and Restorative Services (Policy OCA 3.69), Effective 07/01/20
Denervation of Facet Joints or Sacroiliac Joints (Policy OCA 3.70), Effective 02/01/21
Drug Screening/Testing for Drugs of Abuse and/or Controlled Substances (Policy OCA 3.98), Effective 01/01/21
Electric Tumor Treatment Fields ( Policy OCA 3.29), Effective 03/01/21
Endoscopic Procedures or Magnetic Esophageal Sphincter Augmentation to Treat Gastrointestinal Reflux Disease (GERD) in the Outpatient Setting(Policy OCA 3.46), Effective 10/01/20
Enteral Nutrition(Tube Feeding) Products Supplied and Billed by Home Infusion Providers and Digestive Enzyme Cartridges(Policy OCA 3.37), Effective 10/01/20
Experimental and Investigational Treatment (Policy OCA 3.12), Effective 07/01/20
Facet Joint Nerve Injections (Policy OCA 3.9641), Effective 03/01/21
Facet Joint Nerve Injections (Policy OCA 3.9641), Effective 12/01/20 and Retired 02/28/21
Gender Affirmation Surgeries (Policy OCA 3.11), Effective 02/01/21
Gene Expression Profiling of Tumor Tissue to Predict Cancer Recurrence with Risk Stratification (Including Oncotype DX and Other Tests) (Policy OCA 3.572), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727), Effective 06/01/21 with InterQual Criteria Adopted to Coincide with Policy
Genetic/Genomic Testing and Pharmacogenetics (Policy OCA 3.727), Effective 01/01/21 and Retired 05/31/21 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Familial Malignant Melanoma (Policy OCA 3.78), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Fragile X-Associated Disorders (Policy OCA 3.571), Effective 02/01/20 and Retired 02/28/21 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Fragile X-Associated Disorders (Policy OCA 3.571), Effective 03/01/21 with InterQual Criteria Adopted to Coincide with Policy
Genetic Testing for Hereditary Breast and Ovarian Cancer Syndrome (Policy OCA 3.57), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Colorectal Cancer (Policy OCA 3.64), Retire Medical Policy and Adopt InterQual Criteria as of 10/01/19
Genetic Testing for Hereditary Thrombophilia (Policy OCA 3.728), Effective 03/01/21
Genetic Testing for Hereditary Thrombophilia (Policy OCA 3.728), Effective 04/01/20 and Retired 02/28/21
Gynecomastia Surgery (Policy OCA 3.48), Effective 05/01/20
Home Health Care (Policy OCA 3.719), Effective 09/01/20
Home Health Care (Policy OCA 3.729 QHP), Effective 09/01/20
Home Prothrombin Time Monitoring Devices (Policy OCA 3.27), Effective 01/01/21
Hyperbaric Oxygen Therapy (HBOT) or Topical Oxygen Therapy (TOT) (Policy OCA 3.75) Effective 12/01/20 Used in Conjunction with InterQual Criteria
Implantable Bone-Conduction (Bone-Anchored) Hearing Aids (Policy OCA 3.30), Effective 06/01/20
Infertility Services (Policy OCA 3.725), Effective 10/01/20
Intensity Modulated Radiation Therapy, Outpatient (Policy OCA 3.81), Effective 07/01/20
Mastopexy (Policy OCA 3.717), Effective 05/01/20
Mechanized Spinal Distraction Therapy (Policy OCA 3.84), Effective 03/01/20 and Retired 02/28/21
Mechanized Spinal Distraction Therapy (Policy OCA 3.84), Effective 03/01/21
Medically Necessary (Policy OCA 3.14), Effective 07/01/20
Medically Necessary Facility/Hospital Services for Non-Covered Dental Services (Due to a Serious Medical Condition) (Policy OCA 3.723), Effective 05/01/20
Medical Nutrition Therapy in the Outpatient Setting or Office Setting (Policy OCA 3.66) Effective 08/01/20
Minimally Invasive Procedures and Associated Devices used to Treat Back Pain (Policy OCA 3.713), Effective 05/01/20
Nerve Repairs for Peripheral Nerve Injuries Using Allografts, Autografts, and Conduits (Policy OCA 3.701), Effective 01/01/21
Occipital Nerve Stimulation (Policy OCA 3.501), Effective 02/01/20 and Retired 02/28/21
Occipital Nerve Stimulation (Policy OCA 3.501), Effective 03/01/21
Occupational Therapy in the Outpatient Setting (Policy OCA 3.53), Effective 12/01/20
Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Policy OCA 3.965), Effective 03/01/21
Osteochondral Treatments for Defects of the Knee, Talus, and Other Joints (Policy OCA 3.965), Effective 05/01/20 and Retired 02/28/21
Panniculectomy and Related Redundant Skin Surgery (Policy OCA 3.722), Effective 03/01/21
Panniculectomy and Related Redundant Skin Surgery (Policy OCA 3.722), Effective 12/01/19 and Retired 02/28/21
Pelvic Floor Stimulation for the Treatment of Incontinence and/or Overactive Bladder (Policy OCA 3.561), Effective 10/01/20
Photochemotherapy, Phototherapy or Excimer Laser Therapy for Dermatological Conditions in the Outpatient Setting (Policy OCA 3.39), Effective 02/01/21
Physical Therapy in the Outpatient Setting (Policy OCA 3.54), Effective 12/01/20
Posterior Tibial Nerve Stimulation (Percutaneous or Transcutaneous) (Policy OCA 3.562), Effective 10/01/20
Preimplantation Genetic Testing (Policy OCA 3.726) Effective 12/01/20
Private Duty Nursing Services (Policy OCA 3.715), Effective 09/01/19
Prolotherapy (Policy OCA 3.707), Effective 08/01/20
Pulmonary Rehabilitation, Outpatient (Policy OCA 3.62) Retired Medical Policy and Adopt InterQual Criteria as of 03/01/20
Sacral Nerve Stimulation (Including Peripheral Nerve Stimulation Test) for Incontinence and Urinary Conditions (Policy OCA 3.563), Effective 10/01/20
Sacroiliac Joint Injections (Policy OCA 3.9642), Effective 03/01/20 and Retired 02/28/21
Sacroiliac Joint Injections (Policy OCA 3.9642), Effective 03/01/21
Skin Substitutes in the Outpatient Setting (Policy OCA 3.710), Effective 01/01/21
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 20 or Younger in the Outpatient Setting (Policy OCA 3.55), Effective 12/01/20
Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member Age 21 or Older in the Outpatient Setting (Policy OCA 3.551), Effective 02/01/21
Temporomandibular Joint Disorder Treatment (Policy OCA 3.968), Effective 10/01/20
Transplant Administration (Policy OCA 3.10), Effective 04/01/20
Transplantation of Lung or Lobar Lung (Policy OCA 3.24), Effective 06/01/20
Transplantation of Pancreas or Pancreas-Kidney (Policy OCA 3.25), Effective 06/01/20
Transplantation of Small Bowel, Small Bowel-Liver, or Multivisceral Organs (Policy OCA 3.26), Effective 04/01/20
Video Electroencephalography (EEG) Monitoring (Policy OCA 3.38), Effective 05/01/20
Vision Therapy (Policy OCA 3.40), Effective 02/01/20
Whole Body Integumentary Photography (Policy OCA 3.702), Effective 08/01/20
Type Title Plan Type
Acupuncture Services (Policy 4.4), Effective 10/01/19
MassHealth or QHP
Anesthesia (Policy 4.103), Effective 04/01/20
MassHealth or QHP
Bilateral and Multiple Procedure Reduction (Policy 4.607), Effective 10/01/19
MassHealth or QHP
Chemotherapy (Policy 4.11), Effective 07/01/16
MassHealth or QHP
Chiropractic Services (Policy 4.116), Effective 01/01/2021
MassHealth or QHP
Chiropractic Services (Spinal Manipulation) (Policy 4.116), Effective 01/01/20 and Retired 12/31/20
MassHealth or QHP
Chronic Maintenance Dialysis performed in Freestanding Dialysis Clinics (Policy 4.95), Effective 07/01/19
MassHealth or QHP
Clinical Trials (Policy 4.134), Effective 07/01/2019
MassHealth or QHP
Community Health Centers and Federally Qualified Health Centers (Policy 4.107), Effective 08/01/18
MassHealth or QHP
Dental Services (Policy 4.15), Effective 01/01/20
MassHealth or QHP
Diabetes Self-Management Training / Medical Nutrition Therapy (Policy 4.32), Effective 05/01/18
MassHealth or QHP
Drug Screening/Testing (DS/T): Drugs of Abuse (Policy 4.94), Effective 04/15/2020
MassHealth or QHP
Early Intervention (Policy 4.3), Effective 01/01/20
MassHealth or QHP
Family Planning, Sterilization and Abortion Services (Policy 4.115), Effective 07/01/19
MassHealth or QHP
Free Standing Surgical Facility (Policy 4.114), Effective 01/01/20
MassHealth or QHP
General Billing and Coding Guidelines (Policy 4.31), Effective 04/01/20
MassHealth or QHP
General Clinical Editing and Payment Accuracy Review Guidelines (Policy 4.108), Effective 11/01/18
MassHealth or QHP
Hearing Aid Dispensing and Repairs (Policy 4.111), Effective 01/01/19
MassHealth or QHP
Home Health (Policy 4.7), Effective 07/01/19
MassHealth or QHP
Home Infusion including Parenteral/Tube Fed Enteral Nutritional Therapy (Policy 4.121), Effective 01/01/20
MassHealth or QHP
Hospice (Policy 4.8), Effective 04/01/20
MassHealth or QHP
Immunization Services (Policy 4.117), Effective 05/01/18
MassHealth or QHP
Infertility Services (Policy 4.34), Effective 10/01/19
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 01/01/21
MassHealth or QHP
Inpatient Hospital (Policy 4.110), Effective 12/01/19 and Retired 12/31/20
MassHealth or QHP
Modifiers (Policy 4.23), Effective 05/15/19
MassHealth or QHP
Newborn and Neonatal Intensive Care Unit (NICU) Services (Policy 4.106), Effective 09/01/15
MassHealth or QHP
Non-Priced Codes (Policy 4.37), Effective 07/01/19
MassHealth or QHP
Non-Reimbursed Codes (Policy 4.48), Effective 01/01/2021
MassHealth or QHP
Non-Reimbursed Codes (Policy 4.48), Effective 04/01/20 and Retired 12/31/20
MassHealth or QHP
Observation Services (Policy 4.36), Effective 01/01/2021
MassHealth or QHP
Observation Services (Policy 4.36), Effective 12/30/16 and Retired 12/31/20
MassHealth or QHP
Obstetrical (Policy 4.105), Effective 04/17/17
MassHealth or QHP
Outpatient Hospital (Policy 4.17), Effective 01/01/2021
MassHealth or QHP
Outpatient Hospital (Policy 4.17), Effective 04/01/2020 and Retired 12/31/20
MassHealth or QHP
Physical, Occupational and Speech Rehabilitation Modalities and Therapeutic Procedures (Policy 4.609), Effective 01/01/20
MassHealth or QHP
Physician and Non-Physician Practitioner Services (Policy 4.608), Effective 10/01/19
MassHealth or QHP
Preventive Services (Policy 4.6), Effective 01/01/2021
MassHealth or QHP
Preventive Services (Policy 4.6), Effective 10/01/19 and Retired 12/31/20
MassHealth or QHP
Private Duty Nursing (Policy 4.39), Effective 03/01/18
MassHealth or QHP
Provider Preventable Conditions and Serious Reportable Events (Policy 4.610), Effective 07/01/19
MassHealth or QHP
Sleep Studies (Policy 4.5), Effective 01/01/2021
MassHealth or QHP
Sleep Studies (Policy 4.5), Effective 08/01/19 and Retired 12/31/20
MassHealth or QHP
Telemedicine Services (Policy 4.33), Effective 01/01/21
MassHealth or QHP
Telemedicine Services (Policy 4.33)), Effective 01/01/19 and Retired 12/31/2020
MassHealth or QHP
Transportation (Policy 4.113), Effective 01/01/20
MassHealth or QHP
Urgent Care (Policy 4.96), Effective 01/01/2021
MassHealth or QHP
Urgent Care (Policy 4.96), Effective 10/01/18 and Retired 12/31/20
MassHealth or QHP
Vision Services (Policy 4.38), Effective 04/01/19
MassHealth or QHP
Adult and Group Foster Care (SCO 4.21), Effective 04/01/19
SCO
Adult Day Health (SCO 4.20), Effective 06/01/20
SCO
Aging Service Access Points (ASAP) (SCO 4.24), Effective 04/01/19
SCO
Ambulance (SCO 4.113), Effective 06/01/20
SCO
Ambulatory Surgical Center - Facility (SCO 4.114), Effective 01/01/20
SCO
Anesthesia (SCO 4.103), Effective 04/01/20
SCO
Bilateral and Multiple Procedure Reductions (SCO 4.607), Effective 04/01/20
SCO
Chiropractic Services (SCO 4.116), Effective 01/01/21
SCO
Chiropractic Services (Spinal Manipulation) (SCO 4.116), Effective 01/01/20 and Retired 12/31/20
SCO
Clinical Trials, (SCO 4.134), Effective 07/01/2019
SCO
Day Habilitation (SCO 4.22), Effective 10/01/19
SCO
End-Stage Renal Disease -Dialysis (SCO 4.95), Effective 07/01/19
SCO
General Billing and Coding Guidelines (SCO 4.31), Effective 04/01/20
SCO
General Clinical Editing and Payment Accuracy Review Guidelines (SCO 4.108), Effective 11/01/18
SCO
Hearing Aid Dispensing and Repairs (SCO 4.111), Effective 01/01/19
SCO
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 01/01/2021: Episodes beginning on or after 01/01/2021
SCO
Home Health Agency Services: Medicare-Certified (SCO 4.7), Effective 01/01/2020 and Retired: Episodes beginning on or after 01/01/2020 and before 12/31/2020
SCO
Home Health Agency Services: Non-Medicare Certified (SCO 4.6), Effective 05/01/2019
SCO
Home Infusion Therapy (SCO 4.121), Effective 01/01/2021
SCO
Hospice (SCO 4.8), Effective 04/01/20
SCO
Inpatient Rehabilitation Hospital (SCO 4.71), Effective 01/01/20
SCO
Inpatient (SCO 4.110), Effective 10/01/18
SCO
Modifiers, (SCO 4.23) Effective 10/1/20
SCO
Non-Participating Provider, (SCO 4.5) Effective 10/1/20
SCO
Outpatient Hospital (SCO 4.17), Effective 01/01/2021
SCO
Outpatient Hospital (SCO 4.17), Effective 01/01/16 and Retired 12/31/20
SCO
Outpatient Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) (SCO 4.609), Effective 01/01/20
SCO
Personal Care Attendant (SCO 4.25), Effective 01/01/20
SCO
Personal Care Management Services (SCO 4.26), Effective 01/01/20
SCO
Physician / Non-Physician Practitioner Services (SCO 4.608), Effective 07/01/19
SCO
Podiatry Services (SCO 4.72), Effective 10/01/19
SCO
Private Duty Nursing (SCO 4.27), Effective 01/01/20
SCO
Provider Preventable Conditions (PPC) and Serious Reportable Events (SRE) (SCO 4.610), Effective 07/01/19
SCO
Type Title Plan Type
Chronic Myelogenous Leukemia (CML) Agents - Unified Formulary (Policy MA9.709), Effective 01/20/2021
Mass Health
Age & Quantity Limitation Program Policy (Policy MA9.050), Effective 01/01/2021
Mass Health
Non-Formulary Exceptions (Policy MA9.051), Effective 01/01/2021
Mass Health
Cystic Fibrosis Agents (Policy MA9.100), Effective 01/01/2021
Mass Health
Hereditary Angioedema (Policy MA9.101), Effective 01/01/2021
Mass Health
Sublingual Immunotherapy (SLIT) Medications (Policy MA9.104), Effective 01/01/2021
Mass Health
Esbriet (Policy MA9.105), Effective 01/01/2021
Mass Health
Nplate (Policy MA9.106), Effective 01/01/2021
Mass Health
Promacta (Policy MA9.107), Effective 01/01/2021
Mass Health
Kyrstexxa (Pegloticase) (Policy MA9.108), Effective 01/01/2021
Mass Health
Immune Globulin (Policy MA9.110), Effective 01/01/2021
Mass Health
Daliresp (Policy MA9.111), Effective 01/01/2021
Mass Health
Acthar H.P. Gel (Policy MA9.112), Effective 01/01/2021
Mass Health
Benlysta (Belimumab) (Policy MA9.115), Effective 01/01/2021
Mass Health
Entyvio (Policy MA9.120), Effective 01/01/2021
Mass Health
Infliximab Products (Policy MA9.123), Effective 01/01/2021
Mass Health
Methotrexate (Policy MA9.125), Effective 01/01/2021
Mass Health
Complement Inhibitors (Policy MA9.134), Effective 01/01/2021
Mass Health
Lambert Eaton Myasthenic Syndrome (Policy MA9.135), Effective 01/01/2021
Mass Health
Levalbuterol Nebulizer Solution (Policy MA9.147), Effective 01/25/2021
Mass Health
Diacomit (Policy MA9.201), Effective 01/01/2021
Mass Health
Myalept (Policy MA9.307), Effective 01/01/2021
Mass Health
Natpara (Policy MA9.309), Effective 01/01/2021
Mass Health
Kanuma (Policy MA9.311), Effective 01/01/2021
Mass Health
Strensiq (Policy MA9.312), Effective 01/01/2021
Mass Health
Cerdelga (Policy MA9.313), Effective 01/01/2021
Mass Health
Rayaldee (Policy MA9.314), Effective 01/01/2021
Mass Health
Spinraza (Policy MA9.315), Effective 01/01/2021
Mass Health
Mepsevii (Policy MA9.316), Effective 01/01/2021
Mass Health
Increlex (Policy MA9.317), Effective 01/01/2021
Mass Health
Metabolic Bone Disease Agents (Policy MA9.318), Effective 01/01/2021
Mass Health
Samsca (Policy MA9.319), Effective 01/01/2021
Mass Health
Givlaari (Policy MA9.321), Effective 01/01/2021
Mass Health
Crysvita (Policy MA9.324), Effective 01/01/2021
Mass Health
Step Therapy Policy - Bisphosphonates (Policy MA9.329), Effective 01/01/2021
Mass Health
Spinal Muscular Atrophy (SMA) Agents - Unified Formulary (Policy MA9.331), Effective 01/01/2021
Mass Health
Antidiabetic Agents - Unified Formulary (Policy MA9.332), Effective 01/20/2021
Mass Health
Glucagon Products - Unified Formulary (Policy MA9.333), Effective 01/01/2021
Mass Health
Growth Hormone Agents - Unified Formulary (Policy MA9.334), Effective 01/01/2021
Mass Health
Insulin Products - Unified Formulary (Policy MA9.335), Effective 01/19/2021
Mass Health
Diabetic Testing Supplies - United Formulary (Policy MA9.336), Effective 01/01/2021
Mass Health
Pyrimethamine (Daraprim) (Policy MA9.401), Effective 01/01/2021
Mass Health
Impavido (Policy MA9.402), Effective 01/01/2021
Mass Health
Systemic Antibiotics (Policy MA9.403), Effective 01/01/2021
Mass Health
Synagis (Policy MA9.405), Effective 01/01/2021
Mass Health
Antifungal Agents (Policy MA9.406), Effective 01/01/2021
Mass Health
Step Therapy Policy - Pediculicides (Policy MA9.408), Effective 01/01/2021
Mass Health
Hepatitis Antiviral Agents - Unified Formulary (Policy MA9.409), Effective 01/01/2021
Mass Health
Pediatric Behavioral Health Medication Initiative (Policy MA9.500), Effective 01/01/2021
Mass Health
Lucemyra (Policy MA9.501), Effective 01/01/2021
Mass Health
Antidepressants (Policy MA9.502), Effective 01/01/2021
Mass Health
Antipsychotics (Policy MA9.503), Effective 01/01/2021
Mass Health
Buprenorphine and Naloxone Products (Policy MA9.504), Effective 01/01/2021
Mass Health
ADHD Medications (Policy MA9.505), Effective 01/01/2021
Mass Health
Step Therapy Policy - Antidepressant and Antipsychotic Agents (Policy MA9.506), Effective 01/01/2021
Mass Health
Antipsychotics - Unified Formulary (Policy MA9.507), Effective 01/19/2021
Mass Health
Cerebral Stimulants and ADHD Medications - Unified Formulary (Policy MA9.508), Effective 01/01/2021
Mass Health
Opioid Dependence - Unified Formulary (Policy MA9.509), Effective 01/01/2021
Mass Health
Pulmonary Hypertension (Policy MA9.600), Effective 01/01/2021
Mass Health
ACEIs and ARBs (Policy MA9.601), Effective 01/01/2021
Mass Health
Beta Blockerss (Policy MA9.602), Effective 01/01/2021
Mass Health
Homozygous Familial Hypercholesterolemia (Policy MA9.603), Effective 01/01/2021
Mass Health
Northera (Policy MA9.604), Effective 01/01/2021
Mass Health
PCSK9 Inhibitors (Policy MA9.605), Effective 01/01/2021
Mass Health
Entresto (Policy MA9.606), Effective 01/01/2021
Mass Health
Omega Fatty Acids (Policy MA9.607), Effective 01/01/2021
Mass Health
Ranolazine ER (Policy MA9.608), Effective 01/01/2021
Mass Health
Blood Clotting Disorder Medications (Policy MA9.610), Effective 01/01/2021
Mass Health
Adakveo (Policy MA9.611), Effective 01/01/2021
Mass Health
Oxbryta (Policy MA9.612), Effective 01/01/2021
Mass Health
Reblozyl (Policy MA9.613), Effective 01/01/2021
Mass Health
Step Therapy Policy - Antihypertensive Agents (Policy MA9.615), Effective 01/01/2021
Mass Health
Erythropoiesis Stimulating Agents (ESAs) - Unified Formulary (Policy MA9.617), Effective 01/20/2021
Mass Health
Step Therapy Policy - Anti-Platelet Agents (Policy MA9.618), Effective 01/01/2021
Mass Health
Anticoagulants - Unified Formulary (Policy MA9.619), Effective 01/01/2021
Mass Health
Granulocyte Stimulating Agents - Unified Formulary (Policy MA9.621), Effective 01/01/2021
Mass Health
Antineoplastic Agents (Policy MA9.700), Effective 01/01/2021
Mass Health
Xermelo (Policy MA9.701), Effective 01/01/2021
Mass Health
Mozobil (Policy MA9.702), Effective 01/01/2021
Mass Health
GnRH Agents (Policy MA9.703), Effective 01/01/2021
Mass Health
Rituximab (Policy MA9.704), Effective 01/01/2021
Mass Health
Tepezza (Policy MA9.705), Effective 01/01/2021
Mass Health
Enhertu (Policy MA9.706), Effective 01/01/2021
Mass Health
Padcev (Policy MA9.707), Effective 01/01/2021
Mass Health
Breast Cancer Therapies - Unified Formulary (Policy MA9.708), Effective 01/01/2021
Mass Health
Colorectal Cancer Agents - Unified Formulary (Policy MA9.710), Effective 01/01/2021
Mass Health
Kinase Inhibitors - Unified Formulary (Policy MA9.711), Effective 01/20/2021
Mass Health
Lung Cancer Agents - Unified Formulary (Policy MA9.712), Effective 01/01/2021
Mass Health
Lymphoma and Leukemia Agents - Unified Formulary (Policy MA9.713), Effective 01/01/2021
Mass Health
Melanoma Agents - Unified Formulary (Policy MA9.714), Effective 01/01/2021
Mass Health
Medullary Thyroid Cancer Agents - Unified Formulary (Policy MA9.715), Effective 01/01/2021
Mass Health
Turalio - Unified Formulary (Policy MA9.717), Effective 01/01/2021
Mass Health
JAK Inhibitors - Unified Formulary (Policy MA9.718), Effective 01/01/2021
Mass Health
Hydroxyprogesterone Caproate (Policy MA9.800), Effective 01/01/2021
Mass Health
Tranexamic Acid (Policy MA9.801), Effective 01/01/2021
Mass Health
Gattex (Policy MA9.802), Effective 01/01/2021
Mass Health
Ocaliva (Policy MA9.803), Effective 01/01/2021
Mass Health
Gastrointestinal Agents (Policy MA9.804), Effective 01/01/2021
Mass Health
Benign Prostatic Hyperplasia (BPH) Medications (Policy MA9.805), Effective 01/01/2021
Mass Health
Step Therapy Policy - Proton Pump Inhibitors (Policy MA9.806), Effective 01/01/2021
Mass Health
Step Therapy Policy - Urinary Antispasmodic Agents (Policy MA9.807), Effective 01/01/2021
Mass Health
Ophthalmic Antibodies (Policy MA9.901), Effective 01/01/2021
Mass Health
Restasis, Xiidra (Policy MA9.902), Effective 01/01/2021
Mass Health
Mytesi (Policy MA9.903), Effective 01/01/2021
Mass Health
Luxterna (Policy MA9.904), Effective 01/01/2021
Mass Health
Antiemetics (Policy MA9.905), Effective 01/01/2021
Mass Health
Anabolic Steroids - Anadrol, Oxandrolone (Policy MA9.907), Effective 01/01/2021
Mass Health
Acne and Rosacea Agents (Policy MA9.908), Effective 01/01/2021
Mass Health
Viscosupplements (Policy MA9.909), Effective 01/01/2021
Mass Health
Bile Acid Sequestrants (Policy MA9.910), Effective 01/01/2021
Mass Health
Xiaflex (Policy MA9.911), Effective 01/01/2021
Mass Health
Rhopressa (Netrasudil) (Policy MA9.912), Effective 01/01/2021
Mass Health
Step Therapy Policy - Glaucoma (Policy MA9.913), Effective 01/01/2021
Mass Health
Step Therapy Policy - Miscellaneous Ophthalmic Policy (Policy MA9.915), Effective 01/01/2021
Mass Health
Step Therapy Policy - Topical Acne Agents (Policy MA9.916), Effective 01/01/2021
Mass Health
Step Therapy Policy - Topical Lidocaine (Policy MA9.917), Effective 01/01/2021
Mass Health
Step Therapy Policy - Topical Steroids (Policy MA9.918), Effective 01/01/2021
Mass Health
Trientine (Syprine) (Policy MA9.310), Effective 01/01/2021
Mass Health
Vyndaqel, Vyndamax (Policy MA9.323), Effective 01/01/2021
Mass Health
Neurotrophic Receptor Tyrosine Kinase Inhibitors (NRTK) Inhibitors - Unified Formulary (Policy MA9.716), Effective 01/01/2021
Mass Health
Topical Medications (MISC) (Policy MA9.906), Effective 01/01/2021
Mass Health
Inbrija (Policy MA9.213), Effective 01/01/2021
Mass Health
Cuvposa (Glycopyrrolate) (Policy MA9.203), Effective 01/01/2021
Mass Health
Multiple Sclerosis - Unified Formulary (Policy MA9.219), Effective 01/19/2021
Mass Health
Step Therapy Policy - Migraine Agents (Policy MA9.215), Effective 01/01/2021
Mass Health
Cholbam (Policy MA9.308), Effective 01/01/2021
Mass Health
Asthma and Allergy Monoclonal Antibodies - Unified Formulary (Policy MA9.143), Effective 01/01/2021
Mass Health
Step Therapy Policy - NSAIDS (Policy MA9.218), Effective 01/01/2021
Mass Health
Korlym (Policy MA9.303), Effective 01/01/2021
Mass Health
Step Therapy Policy - Oral and Nasal Allergy Agents (Policy MA9.142), Effective 01/01/2021
Mass Health
Arcalyst and Ilaris - Unified Formulary (Policy MA9.145), Effective 01/01/2021
Mass Health
Calcitonin-Gene Related Peptide (CGRP) Inhibitors - Unified Formulary (Policy MA9.220), Effective 01/19/2021
Mass Health
Urea Cycle Disorder Agents (Policy MA9.305), Effective 01/01/2021
Mass Health
Lambert Eaton Myasthenic Syndrome (Policy MA9.135), Effective 01/01/2021
Mass Health
Osphena (Policy MA9.300), Effective 01/01/2021
Mass Health
Step Therapy Policy - Gout (Policy MA9.137), Effective 01/01/2021
Mass Health
Brineura (Policy MA9.301), Effective 01/01/2021
Mass Health
Duchenne Muscular Dystrophy Agents (Policy MA9.302), Effective 01/01/2021
Mass Health
Ofev (Policy MA9.133), Effective 01/01/2021
Mass Health
Pregabalin (Policy MA9.206), Effective 01/01/2021
Mass Health
Egrifta (Policy MA9.304), Effective 01/01/2021
Mass Health
Signifor (Policy MA9.306), Effective 01/01/2021
Mass Health
Tavalisse (Policy MA9.136), Effective 01/01/2021
Mass Health
Immune Suppressants - Topical - Unified Formulary (Policy MA9.139), Effective 01/01/2021
Mass Health
Step Therapy Policy - Pulmonary Agents (Policy MA9.138), Effective 01/01/2021
Mass Health
Nuedexta (Policy MA9.200), Effective 01/01/2021
Mass Health
Narcolepsy (Policy MA9.208), Effective 01/01/2021
Mass Health
Targeted Immunomodulators (TIMs) - Unified Formulary (Policy MA9.144), Effective 01/01/2021
Mass Health
Opioids (Policy MA9.210), Effective 01/01/2021
Mass Health
Insomnia Agents (Policy MA9.211), Effective 01/01/2021
Mass Health
Savella (Policy MA9.202), Effective 01/01/2021
Mass Health
VMAT 2 Inhibitors (Policy MA9.204), Effective 01/01/2021
Mass Health
Tramadol ER (Policy MA9.207), Effective 01/01/2021
Mass Health
Respiratory Agents - Unified Formulary (Policy MA9.141), Effective 01/01/2021
Mass Health
Step Therapy Policy - Anti-Parkinson Agents (Policy MA9.217), Effective 01/01/2021
Mass Health
Step Therapy Policy - Anticonvulsant Agents (Policy MA9.214), Effective 01/01/2021
Mass Health
Botox (Policy MA9.209), Effective 01/01/2021
Mass Health
Age & Quantity Limitation Program Policy (Policy QHP9.050), Effective 01/01/2021
Qualified Health Plan
Non-Formulary Exceptions (Policy QHP9.051), Effective 01/01/2021
Qualified Health Plan
Cystic Fibrosis Agents (Policy QHP9.100), Effective 01/01/2021
Qualified Health Plan
Hereditary Angioedema (Policy QHP9.101), Effective 01/01/2021
Qualified Health Plan
Rinvoq (Policy QHP9.102), Effective 01/01/2021
Qualified Health Plan
Topical Immunomodulators (Policy QHP9.103), Effective 01/01/2021
Qualified Health Plan
Sublingual Immunotherapy (SLIT) Medications (Policy QHP9.104), Effective 01/01/2021
Qualified Health Plan
Esbriet (Policy QHP9.105), Effective 01/01/2021
Qualified Health Plan
Promacta (Policy QHP9.107), Effective 01/01/2021
Qualified Health Plan
Asthma-Allergy Monoclonal Antibodies (Policy QHP9.109), Effective 01/01/2021
Qualified Health Plan
Immune Globulin (Policy QHP9.110), Effective 01/01/2021
Qualified Health Plan
Acthar H.P. Gel (Policy QHP9.112), Effective 01/01/2021
Qualified Health Plan
Acterma (Tocilizumab) (Policy QHP9.113), Effective 01/01/2021
Qualified Health Plan
Arcalyst (Rilonacept) (Policy QHP9.114), Effective 01/01/2021
Qualified Health Plan
Benlysta (Belimumab) (Policy QHP9.115), Effective 01/01/2021
Qualified Health Plan
Cimzia (Certolizumab pegol) (Policy QHP9.116), Effective 01/01/2021
Qualified Health Plan
Cosentyx (Secukinumab) (Policy QHP9.117), Effective 01/01/2021
Qualified Health Plan
Dupixent (Dupilumab) (Policy QHP9.118), Effective 01/01/2021
Qualified Health Plan
Enbrel (Etanercept) (Policy QHP9.119), Effective 01/01/2021
Qualified Health Plan
Entyvio (Policy QHP9.120), Effective 01/01/2021
Qualified Health Plan
Humira (Policy QHP9.121), Effective 01/01/2021
Qualified Health Plan
Infliximab Products (Policy QHP9.123), Effective 01/01/2021
Qualified Health Plan
Methotrexate (Policy QHP9.125), Effective 01/01/2021
Qualified Health Plan
Otezla (Policy QHP9.127), Effective 01/01/2021
Qualified Health Plan
Stelara (Policy QHP9.129), Effective 01/01/2021
Qualified Health Plan
Taltz (Policy QHP9.130), Effective 01/01/2021
Qualified Health Plan
Xeljanz (Policy QHP9.131), Effective 01/01/2021
Qualified Health Plan
Ofev (Policy QHP9.133), Effective 01/01/2021
Qualified Health Plan
Tavalisse (Policy QHP9.136), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Gout Agents (Policy QHP9.137), Effective 01/01/2021
Qualified Health Plan
Step Therapy- Pulmonary Agents (Policy QHP9.138), Effective 01/01/2021
Qualified Health Plan
Skyrizi (risankizumab-rzaa) (Policy QHP9.140), Effective 01/01/2021
Qualified Health Plan
Actimmune (Policy QHP9.146), Effective 01/01/2021
Qualified Health Plan
Nuedexta (Policy QHP9.200), Effective 01/01/2021
Qualified Health Plan
Savella (Policy QHP9.202), Effective 01/01/2021
Qualified Health Plan
VMAT 2 Inhibitors (Policy QHP9.204), Effective 01/01/2021
Qualified Health Plan
Calcitonin-Gene Related Peptide Antagonist (CGRP) (Policy QHP9.205), Effective 01/01/2021
Qualified Health Plan
Pregabalin (Policy QHP9.206), Effective 01/01/2021
Qualified Health Plan
Narcolepsy (Policy QHP9.208), Effective 01/01/2021
Qualified Health Plan
Botox (Policy QHP9.209), Effective 01/01/2021
Qualified Health Plan
Opioids (Policy QHP9.210), Effective 01/01/2021
Qualified Health Plan
Insomnia Agents (Policy QHP9.211), Effective 01/01/2021
Qualified Health Plan
Multiple Sclerosis (Policy QHP9.212), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Anticonvulsants (Policy QHP9.214), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Migraine Agents (Policy QHP9.215), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Sleep Disorder Agents (Policy QHP9.216), Effective 01/01/2021
Qualified Health Plan
Epidolex (Policy QHP9.222), Effective 01/01/2021
Qualified Health Plan
Vigabatrin (Policy QHP9.223), Effective 01/01/2021
Qualified Health Plan
Egrifta (Policy QHP9.304), Effective 01/01/2021
Qualified Health Plan
Signifor (Policy QHP9.306), Effective 01/01/2021
Qualified Health Plan
Myalept (Policy QHP9.307), Effective 01/01/2021
Qualified Health Plan
Rayaldee (Policy QHP9.314), Effective 01/01/2021
Qualified Health Plan
Increlex (Policy QHP9.317), Effective 01/01/2021
Qualified Health Plan
Metabolic Bone Disease Agents (Policy QHP9.318), Effective 01/01/2021
Qualified Health Plan
Samsca (Policy QHP9.319), Effective 01/01/2021
Qualified Health Plan
Non-Preferred Blood Glucose Testing Products (Policy QHP9.320), Effective 01/01/2021
Qualified Health Plan
Givlaari (Policy QHP9.321), Effective 01/01/2021
Qualified Health Plan
Anti-Obesity Medications (Policy QHP9.322), Effective 01/01/2021
Qualified Health Plan
Genotropin (Policy QHP9.325), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Antidiabetic Agents (Policy QHP9.327), Effective 01/01/2021
Qualified Health Plan
Somavert (Pegvisomant) (Policy QHP9.328), Effective 01/01/2021
Qualified Health Plan
Topical Acyclovir (Policy QHP9.400), Effective 01/01/2021
Qualified Health Plan
Systemic Antibiotics (Policy QHP9.403), Effective 01/01/2021
Qualified Health Plan
Hepatitis C (Policy QHP9.404), Effective 01/01/2021
Qualified Health Plan
Synagis (Policy QHP9.405), Effective 01/01/2021
Qualified Health Plan
Antifungal Agents (Policy QHP9.406), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Pediculicide Agents (Policy QHP9.408), Effective 01/01/2021
Qualified Health Plan
Chloroquine and Hydroxychloroquine (Policy QHP9.410), Effective 01/01/2021
Qualified Health Plan
Descovy (Policy QHP9.411), Effective 01/01/2021
Qualified Health Plan
Sirturo (Policy QHP9.412), Effective 01/01/2021
Qualified Health Plan
Antipsychotics (Policy QHP9.503), Effective 01/01/2021
Qualified Health Plan
Buprenorphine and Naloxone Products (Policy QHP9.504), Effective 01/21/2021
Qualified Health Plan
ADHD Medications (Policy QHP9.505), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Anti-Depressant / Anti-Psychotic Agents (Policy QHP9.506), Effective 01/01/2021
Qualified Health Plan
Pulmonary Hypertension (Policy QHP9.600), Effective 01/01/2021
Qualified Health Plan
ACEIs and ARBSs (Policy QHP9.601), Effective 01/01/2021
Qualified Health Plan
Homozygous Familial Hypercholesterolemia (Policy QHP9.603), Effective 01/01/2021
Qualified Health Plan
Northera (Policy QHP9.604), Effective 01/01/2021
Qualified Health Plan
PCSK9 Inhibitors (Policy QHP9.605), Effective 01/01/2021
Qualified Health Plan
Entresto (Policy QHP9.606), Effective 01/01/2021
Qualified Health Plan
Erythropoiesis Stimulating Agents (Policy QHP9.609), Effective 01/01/2021
Qualified Health Plan
Adakveo (Policy QHP9.611), Effective 01/01/2021
Qualified Health Plan
Oxbryta (Policy QHP9.612), Effective 01/01/2021
Qualified Health Plan
Reblozyl (Policy QHP9.613), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Antihypertensive Agents (Policy QHP9.615), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Dyslipidemia Agents
Qualified Health Plan
Corlanor (Policy QHP9.620), Effective 01/01/2021
Qualified Health Plan
Pegfilgrastim Agents (Policy QHP9.622), Effective 01/01/2021
Qualified Health Plan
Iron Chelating Agents (Policy QHP9.625), Effective 01/01/2021
Qualified Health Plan
Kuvan (Policy QHP9.626), Effective 01/01/2021
Qualified Health Plan
Mulpleta (Policy QHP9.627), Effective 01/01/2021
Qualified Health Plan
Pradaxa (Policy QHP9.628), Effective 01/01/2021
Qualified Health Plan
Antineoplastic Agents (Policy QHP9.700), Effective 01/01/2021
Qualified Health Plan
GnRH Agents (Policy QHP9.703), Effective 01/01/2021
Qualified Health Plan
Rituximab (Policy QHP9.704), Effective 01/01/2021
Qualified Health Plan
Tepezza (Policy QHP9.705), Effective 01/01/2021
Qualified Health Plan
Enhertu (Policy QHP9.706), Effective 01/01/2021
Qualified Health Plan
Padcev (Policy QHP9.707), Effective 01/01/2021
Qualified Health Plan
Benign Prostatic Hyperplasia (BPH) Medications (Policy QHP9.805), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Proton Pump Inhibitors (Policy QHP9.806), Effective 01/01/2021
Qualified Health Plan
Infertility Medications (Policy QHP9.808), Effective 02/01/2021
Qualified Health Plan
Mytesi (Policy QHP9.903), Effective 01/01/2021
Qualified Health Plan
Antiemetics (Policy QHP9.905), Effective 01/01/2021
Qualified Health Plan
Topical Corticosteroids (Policy QHP9.906), Effective 02/03/2021
Qualified Health Plan
Anabolic Steroids - Anadrol, Oxandrolone (Policy QHP9.907), Effective 01/01/2021
Qualified Health Plan
Acne and Rosacea Agents (Policy QHP9.908), Effective 02/03/2021
Qualified Health Plan
Viscosupplements (Policy QHP9.909), Effective 01/01/2021
Qualified Health Plan
Rhopressa (Netarsudil) (Policy QHP9.912), Effective 01/01/2021
Qualified Health Plan
Step Therapy - Glaucoma (Policy QHP9.913), Effective 01/01/2021
Qualified Health Plan
Anti-Allergy Ophthalmic Agents (Policy QHP9.914), Effective 01/01/2021
Qualified Health Plan

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