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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.
500MG TABS
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Note TitlePrior Authorization Required for Prescription Coverage of More Than 10 DaysDefinitionEffective April 1, 2020 until further notice, this medication will have quantity limits for first-time prescriptions for new therapies. If prescribed for more than 10 days, your doctor will be required to obtain Prior Authorization from us before additional medication can be covered and dispensed
50MG/ML SOLN
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Note TitlePrior Authorization Required for Prescription Coverage of More Than 10 DaysDefinitionEffective April 1, 2020 until further notice, this medication will have quantity limits for first-time prescriptions for new therapies. If prescribed for more than 10 days, your doctor will be required to obtain Prior Authorization from us before additional medication can be covered and dispensed
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
Important Information
Affordable Care Act (ACA) Medication List
Medical Benefit Prior Authorization Medication List
Over-the-Counter Exclusion Medication List
Quality Care Dosing Guidelines
Learn About Your Pharmacy Program
Learn About Your Pharmacy Program
Affordable Care Act (ACA) Medication List
Cost-Share Assistance Program Medication List
Health Savings Account (HSA) Preventive Medication List
Lower-Cost, Brand-Name Insulins Medication List
Medical Benefit Prior Authorization Medication List
No-Cost Generic Medications List
Over-the-Counter Exclusion Medication List
Specialty Pharmacy
Specialty Pharmacy Medication List
5-Tier Specialty Pharmacy Medication List
6-Tier Specialty Pharmacy Medication List