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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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.
VAFSEO
THERAPEUTIC CLASS: HEMATOLOGICAL AGENTS - MISC.
Select a strength to see details
150MG TABS
300 MG TABS
300 MG TABS
Not Covered by a 3-Tier Plan
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Note TitleNot CoveredDefinitionThis 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.
Prior Authorization Forms
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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
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Learn About Your Pharmacy Program
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Alternatives to Opioids
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