Note Title
Not Covered
Definition
This medication is excluded from the pharmacy benefit. It is covered by the medical benefit. Please talk to your doctor about alternatives or other covered options.
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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.
VIADUR
THERAPEUTIC CLASS: LHRH Analogs
Select a strength to see details
120MCG/24HR KIT
120MCG/24HR KIT
Not Covered by a 3-Tier Plan
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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
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