Forms, resources, and coverage criteria for your plan
Find all the information you need to enroll in a plan and manage your care.
These resources explain how we define services that are medically necessary.
Explore all Mass General Brigham Advantage medical necessity criteria and guidelines:
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.
These resources explain how to verify prescription drug coverage and how to submit requests and authorizations for medication.
Explore all Mass General Brigham Advantage drug coverage forms and resources:
CVS Caremark Mail Service Order Form (PDF)
CVS Caremark Medicare Part D Prescription Claim Form (PDF)
Medicare Advantage Formulary Notice of Changes – December 2024
Prior Authorization Information
Part B Medical Service Drugs Requiring Prior Authorization (PDF)
These drug requests are submitted to Mass General Brigham Health Plan.
Part B Medical Drugs Requiring Prior Authorization: 2025 | 2024
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: 2025 | 2024
Coverage Determination Requests
Medicare Prescription Drug Coverage Determination Request Form (PDF)
Part B Prescription Medical Drug Organization Determination Request Form (PDF)
Use these forms to enroll in a plan with us or review your rights and responsibilities if you want to change plans.
Individual Enrollment Application 2025 — Mass General Brigham Health Plan (PDF)
Individual Enrollment Application 2024 — Mass General Brigham Health Plan (PDF)
Reimbursement forms
Use these forms to request reimbursements for qualifying healthcare expenses.
Medical Reimbursement Request Form (PDF)
Behavioral Health Reimbursement Request Form (PDF)
2024 Fitness Benefit Coverage Request Form (PDF)
2024 Weight Loss Program Benefit Coverage Request Form (PDF)
EyeMed reimbursement form:
EyeMed Out of Network Reimbursement Form (PDF)
Order forms
Use these forms to order products and prescriptions via mail.
Use this form to give a friend, relative, doctor, or other person the right to legally represent you for healthcare coverage decisions.
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.
Use these documents for help with financial assistance, disaster relief, or to file a grievance or make an appeal.
Getting Care During a Disaster (PDF)
Appeals and Grievances Data Report January 1, 2023 to December 31, 2023:
Use these resources to verify Mass General Brigham Health Plan Medicare star ratings.
2025 ratings
Mass General Brigham Health Plan - H6847
Mass General Brigham Health Plan - H9485
2024 ratings
Mass General Brigham Health Plan - H6847
Mass General Brigham Health Plan - H9485
© 2024 Mass General Brigham Health Plan, Inc. Mass General Brigham Health Plan is an HMO-POS/PPO organization with a Medicare contract. Enrollment in Mass General Brigham Health Plan depends on contract renewal. Other providers/pharmacies are included in our network.
Y0166_0860MKT_M2025A
Last updated: 10/1/2024 - Pending CMS approval