MedicaidPrior AuthHigh impact
MassHealth Unified Formulary and prior authorization updates
Harvard Pilgrim Health Care·MA · Oncology, Hematology, Neurology +2 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
MassHealth is updating their Unified Formulary effective January 5, 2026, and February 17, 2026, with new prior authorization requirements for high-cost specialty drugs including cancer immunotherapies, multiple sclerosis treatments, and other targeted therapies starting January 1, 2026. These changes specifically affect hospital outpatient medical billing for Tufts Health Together MassHealth ACPPs.
Action Required
By January 1, 2026: Billing team must update prior authorization workflows for the listed specialty drugs (Keytruda, Opdivo, Tecentriq, Darzalex, Cimzia, Tremfya, Yervoy, and others) in hospital outpatient settings. Review Point32Health's Unified Medical Policies and Mass.gov Hospital Outpatient PA MHDL Unified Class Drugs list for detailed requirements. Update billing system flags for these medical benefit drugs to prevent claim denials.