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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.
200MG TABS
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Note TitleNot Available Through Mail ServiceDefinitionThis medication is not available through the mail service 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® 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