Note Title
Not Available Through Mail Service
Definition
This medication is not available through the mail service pharmacy
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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.
HETLIOZ
THERAPEUTIC CLASS: ALTERNATIVE MEDICINES*
Select a strength to see details
20MG CAPS
20MG CAPS
Covered by a 3-Tier Plan as a Tier 2 Medication
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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 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 TitleQuality Care DosingDefinitionTo ensure safety and effectiveness, this medication, which is covered through the pharmacy benefit, has quantity and dosage limits that are recommended by the Food and Drug Administration (FDA). Review the Quality Care Dosing Guidelines in the Important Information section to learn more.
4MG/ML ORAL SOLUTION
4MG/ML ORAL SOLUTION
Covered by a 3-Tier Plan as a Tier 2 Medication
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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 ServiceDefinitionThis medication is not available through the mail service pharmacy
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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 TitleQuality Care DosingDefinitionTo ensure safety and effectiveness, this medication, which is covered through the pharmacy benefit, has quantity and dosage limits that are recommended by the Food and Drug Administration (FDA). Review the Quality Care Dosing Guidelines in the Important Information section to learn more.
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
Alternatives to Opioids
For Federal Employee Program Members
Eligible Medicare Members
Covered Alternative Medications