Note Title
Not Available Through Mail Service
Definition
This medication is not available through the mail service pharmacy
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ADCIRCA
THERAPEUTIC CLASS: Selective cGMP Phosphodiesterase Type 5 Inhibitors
Select a strength to see details
20MG TABS
20MG TABS
Not Covered by a 3-Tier Plan
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Note TitleRequires Specialty PharmacyDefinitionThis medication will only be covered through the pharmacy benefit when purchased through a specialty pharmacy that participates in our network. To find a specialty pharmacy, visit Specialty Network Pharmacy Contact Information in the Specialty Pharmacy section.
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Note TitleExceptions To Non Covered MedicationsDefinitionYour doctor may submit a request for an exception. If approved, the medication must still follow any applicable requirements before it can be covered by your plan. You’ll also pay the highest tier cost.
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® Medication Prior Authorization Requests
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