MedicaidPrior AuthMedium impact
Managed Care Entity Bulletin 141: Prior Authorization Requirements for Hospital Outpatient Drugs
MassHealth·MA · Oncology, Hematology, Neurology +1 more·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 in five therapeutic classes: complement inhibitors, multiple myeloma agents, multiple sclerosis agents, oncology immunotherapies, and targeted immunomodulators. This aligns hospital outpatient PA requirements with pharmacy and physician settings for these drug classes.
Action Required
By December 31, 2025: Billing team must update prior authorization workflows for hospital outpatient drugs in five therapeutic classes (complement inhibitors, multiple myeloma agents, multiple sclerosis agents, oncology immunotherapies, and targeted immunomodulators) billed through ACPPs and MCOs. Review the Hospital Outpatient PA MHDL Unified Class Drugs list on the MassHealth website to identify specific affected drugs. Update billing system to flag these drugs for PA requirements when billed in hospital outpatient settings. Note: Emergency, trauma, and urgent care outpatient settings are exempt from PA requirements.