Note Title
Not Available Through Mail Service
Definition
This medication is not available through the mail service pharmacy
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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.
SPEVIGO
THERAPEUTIC CLASS: Immunomodulators**
Select a strength to see details
450MG/7.5ML VIAL
450MG/7.5ML VIAL
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.
150MG/ML PREFILLED SYRINGE
150MG/ML PREFILLED SYRINGE
Covered by a 3-Tier Plan as a Tier 2 Medication
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Note TitleNot Available Through Mail ServiceDefinitionThis medication is not available through the mail service pharmacy
-
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.
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
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