MedicaidPrior AuthHigh impact
Acute Outpatient Hospital Bulletin 44: Prior Authorization Requirements for Hospital Outpatient Drugs
MassHealth·MA·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 18, 2026
Summary
Starting January 1, 2026, MassHealth will require prior authorization for certain hospital outpatient drugs as specified on the MassHealth Drug List for FFS, PCC, and PCACO members. Emergency, trauma, urgent care, and inpatient drugs remain exempt from prior authorization requirements.
Action Required
By December 31, 2025: Billing team must review MassHealth Drug List to identify which hospital outpatient drugs will require prior authorization. Update billing workflows to submit PA requests to MassHealth DUR Program for FFS, PCC, and PCACO members before drug administration. Ensure emergency, trauma, and urgent care settings continue normal billing without PA. Train staff on new PA submission processes to avoid claim denials starting January 1, 2026.