Forms, resources, and coverage criteria

Mass General Brigham Health Plan medical policies

Optum behavioral health criteria

EviCore genetic testing criteria

Medical Necessity Criteria
View medical necessity criteria and guidelines from Mass General Brigham Health Plan.

First time users will be asked to create a One Healthcare ID account. Please enter your name and email address and accept the InterQual End User License Agreement to continue. You will then be redirected to our partner website for medical necessity criteria information.

CVS Caremark Mail Service Order Form (PDF)

CVS Caremark Medicare Part D Prescription Claim Form (PDF)

Coverage Determination Request Form (PDF)

Part B Prescription Medical Drug Organization Determination Request Form (PDF)

Part B Medical Service Drugs Requiring Prior Authorization (PDF)
These drug requests are submitted to Mass General Brigham Health Plan.

2024 plan year information

Medicare Advantage Formulary Notice of Changes – April 2024

Part B Medical Drugs Requiring Prior Authorization (PDF)
Prior authorization is required for the drugs listed within this document when being administered using the member’s medical Part B benefit. Requests for the drugs in this document should be submitted to Novologix.

Part B Medical Drugs Requiring Prior Authorization Guidelines

Individual Enrollment Application — Mass General Brigham Health Plan (PDF)

Disenrollment Rights & Responsibilities (PDF)

Mass General Brigham Health Plan

Medical Reimbursement Request Form (PDF)

Behavioral Health Reimbursement Request Form (PDF)

Fitness Benefit Coverage Request Form (PDF)

Weight Loss Program Benefit Coverage Request Form (PDF)

EyeMed

EyeMed Out of Network Reimbursement Form (PDF)

 

Information release

If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under State law, you do not need to appoint them to represent you. If you want to appoint someone to be your representative, complete the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give Mass General Brigham Health Plan a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.

Authorizations

Request For Medicare Service Coverage Determination (PDF)
This form can be used to submit information to Mass General Brigham Health Plan to help determine if a service or Part B Medical service drug is covered.

Grievances and Appeals (PDF) (Updated 10/1/2022)

2024 Medicare Star Ratings

Mass General Brigham Health Plan - H6847

Mass General Brigham Health Plan - H9485

Extra Help Subsidy (PDF)
Getting Care During a Disaster (PDF)