Massachusetts program
How fast the plan must answer (state deadlines)
Time limits for an insured plan to answer treatment and drug-exception requests under Massachusetts law.
What it is
Time limits for an insured plan to answer treatment and drug-exception requests under Massachusetts law.
A treatment request can stall while an insurer asks for information. State deadlines help identify when an answer is overdue. A separate drug-exception process applies when the plan requires another drug first.
Eligibility rules
- Private self-funded ERISA plans generally follow federal insurance rules. GIC and other public-employer plans need a separate check. The plan and regulator confirm the current rule, effective date and deadline for the actual request.
- The step-therapy rules apply to plans delivered, issued or renewed after October 1, 2023.
What you get
- Time limits for covered initial and ongoing-care requests.
- A separate drug-exception process when trying another medicine first would be unsuitable.
What the help covers
- If the plan misses the drug-exception deadline, the exception counts as granted.
- Once the plan has everything it needs, it must answer a new treatment request within two working days and a request to continue ongoing care within one. A request to skip a "try this drug first" step gets three business days, or 24 hours when delay is dangerous.
If you decide to apply
- Ask the oncology team to confirm what it sent and ask the plan when the request became complete.
- Have the request, plan letters and dates ready.
- If another drug is required first, ask the prescriber about a written exception request and the risk from delay.
The plan, under state law · Official page ↗
After you ask
- The prescriber can document why the required alternative is unsuitable and whether delay creates significant risk.
- Written confirmation of receipt and completeness helps establish whether the deadline has passed.
Good to know
The initial decision clock starts when the plan has all necessary information. The date the clinic first sent a request may be different.
Other details
- State employee and municipal coverage can raise separate applicability questions. Human resources can identify the plan and its governing rules.
Official sources
“If treatment is waiting for the plan, which decision clock applies and would a drug exception help? Could you explain the limits and help the team document a complete request?”
Why I’m asking: I want to know whether an avoidable insurance delay is holding up needed care.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask for dates in writing and hold the plan to them.
Your social worker
The oncology team sends the clinical information and asks for the exception.
The care team
The prescriber makes the exception request and names the contraindication or harm.
- Who decides
- The plan, inside the state clocks.
- Ask the care team
- “Can you confirm in writing the date the plan had everything it needs? Massachusetts gives an insured plan two working days after that, and a step-therapy exception is due in three business days or 24 hours when delay is risky.”
How to apply
First step: Ask the plan in writing for the date it received all the information, and copy the oncology team.
- Ask the plan in writing for the date it had all the information, so the clock is on the record.
- Ask for a step-therapy exception in writing, naming contraindication or likely harm where that applies.
- If a deadline passes on a step-therapy exception, say in writing that it is deemed granted.
Official application / program page ↗
Where it starts: Ask the plan in writing when it received all the information, and ask for the step-therapy exception in writing where a different drug is being pushed.
What to gather
- The authorization request and the date it was sent
- Any letter from the plan
- The prescriber’s exception request
How long: Two working days initially, one for a concurrent review, three business days for a step-therapy exception and 24 hours when delay is risky.
What a yes looks like
An approval, or an exception granted because the plan missed its deadline.
What a no looks like, and the next move
A denial starts the internal grievance and then external review; ask for the expedited route where waiting is harmful.
Watch out
- The clock starts when the plan has everything, so confirm that date in writing.
- A self-funded employer plan is outside these state clocks.
- Some Massachusetts mandates expressly reach state employees insured through the state’s own commission; ask human resources which rules your plan follows.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
Two working days for an initial decision once the plan has all the information, one working day for a concurrent review, and a step-therapy exception in three business days or 24 hours when delay is risky.
- $2 — Working days for an initial prior-authorization decision
- $1 — Working day for a concurrent review decision
- $3 — Business days for a step-therapy exception decision
- $24 — Hours for a step-therapy exception where delay is risky
Legal protection: A step-therapy exception is deemed granted if the plan misses the deadline · Contraindication or likely harm is an express ground for an exception · A plan must tell the treating provider by telephone within 24 hours of approving or denying
What it costs the family: None.
The eligibility facts, as published
- Plan type
- carriers as defined in the chapter; not an employer that merely buys or administers coverage for its own employees
- Applicability
- the step-therapy section applies to plans delivered, issued or renewed after October 1, 2023
The trap: The clocks start when the plan has all the necessary information, so the fastest move is to make sure the team has sent everything and to get that confirmed in writing.
Where I read this
- M.G.L. c. 176O §§ 1, 12, 12A, 14, 15 — health plan rights — Massachusetts General Court, read September 10, 2026