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Medication Lookup
The results below have been sorted using a 2-tier plan. For the most accurate search results, check your plan details and choose another tier plan from the drop-down menu near the search bar.
5MG/2ML CART
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Note TitlePrior Authorization RequiredDefinitionThis medication requires your doctor to obtain prior authorization from us in order to be covered through the pharmacy benefit.
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Note TitleNot Available Through Mail OrderDefinitionThis medication is not available through the mail order pharmacy.
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Note TitleMedical To Pharmacy Benefit TransitionDefinitionThis medication will only be covered through the pharmacy benefit when purchased through a specialty pharmacy that participates in our network. It's not available through outpatient medical coverage, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider. To find a specialty pharmacy, visit Specialty Network Pharmacy Contact Information in the Specialty Pharmacy section.
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Note TitleMedication Not Available Through Medical BenefitDefinitionThis medication will only be only covered through the pharmacy benefit. This medication is not available through the outpatient medical benefit, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider.
10MG/2ML CART
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Note TitlePrior Authorization RequiredDefinitionThis medication requires your doctor to obtain prior authorization from us in order to be covered through the pharmacy benefit.
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Note TitleNot Available Through Mail OrderDefinitionThis medication is not available through the mail order pharmacy.
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Note TitleMedical To Pharmacy Benefit TransitionDefinitionThis medication will only be covered through the pharmacy benefit when purchased through a specialty pharmacy that participates in our network. It's not available through outpatient medical coverage, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider. To find a specialty pharmacy, visit Specialty Network Pharmacy Contact Information in the Specialty Pharmacy section.
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Note TitleMedication Not Available Through Medical BenefitDefinitionThis medication will only be only covered through the pharmacy benefit. This medication is not available through the outpatient medical benefit, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider.
20MG/2ML CART
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Note TitlePrior Authorization RequiredDefinitionThis medication requires your doctor to obtain prior authorization from us in order to be covered through the pharmacy benefit.
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Note TitleNot Available Through Mail OrderDefinitionThis medication is not available through the mail order pharmacy.
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Note TitleMedical To Pharmacy Benefit TransitionDefinitionThis medication will only be covered through the pharmacy benefit when purchased through a specialty pharmacy that participates in our network. It's not available through outpatient medical coverage, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider. To find a specialty pharmacy, visit Specialty Network Pharmacy Contact Information in the Specialty Pharmacy section.
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Note TitleMedication Not Available Through Medical BenefitDefinitionThis medication will only be only covered through the pharmacy benefit. This medication is not available through the outpatient medical benefit, except when administered in a dialysis center, at a surgical day care facility, in an ambulatory surgery center, or through a home infusion therapy provider.
Prior Authorization Forms
Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests
Massachusetts Standard Form for Medication Prior Authorization Requests
Massachusetts Standard Form for Synagis® Prior Authorization Requests
Important Information
Learn About Your Pharmacy Program
Medical Benefit Prior Authorization Medication List
Quality Care Dosing Guidelines
Affordable Care Act (ACA) Covered Medication List
HSA Preventive Medication List
Learn About Your Pharmacy Program
Value-Based Benefit Medications List
Quality Care Dosing Guidelines
Medical Benefit Prior Authorization Medication List
Specialty Pharmacy
Specialty Pharmacy Medication List
5-Tier Specialty Pharmacy Medication List
6-Tier Specialty Pharmacy Medication List
Alternatives to Opioids
For Federal Employee Program Members
View the Federal Employee Program Basic Option Formulary