Note Title
Prior Authorization Required
Definition
This medication requires your doctor to obtain prior authorization from us in order to be covered through the pharmacy benefit.
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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.
IRESSA (Eligible for $0 copay)
THERAPEUTIC CLASS: ANTINEOPLASTICS*
Select a strength to see details
250MG TABS
250MG TABS
Covered by a 3-Tier Plan as a Tier 2 Medication
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Note TitleEligible At No CostDefinitionFor certain plans, this oral chemotherapy medication is available through the pharmacy benefit at no cost ($0) to members.
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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.
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