MedicaidCoverageMedium impact
MassHealth updates to Unified Formulary
Harvard Pilgrim Health Care·MA · Pharmacy·Pharmacy
Effective date
Nov 17, 2025
We identified it
Jun 26, 2026
Summary
MassHealth has updated its Unified Formulary with new coverage and prior authorization criteria effective November 17, 2025. Tufts Health Together-MassHealth MCO Plan and ACPPs will use the updated MassHealth Drug List, requiring billing teams to verify current medication coverage and approval requirements before processing pharmacy claims.
Action Required
By November 17, 2025: Billing team must access the updated MassHealth Drug List on the MassHealth website to identify all formulary changes, new prior authorization requirements, and coverage restrictions. Update billing software and pharmacy claim submission protocols to reflect new coverage criteria for Tufts Health Together-MassHealth MCO Plan and ACPP members. Train billing staff on how to verify medication eligibility before claim submission. Communicate changes to prescribing providers regarding any newly restricted or non-covered medications. Failure to apply updated criteria may result in claim denials and member out-of-pocket costs.