Before prescribing a medication, check the member's pharmacy benefits coverage.
- Use our medication lookup tools first. If the prescription is not covered, the member will pay the full retail cost at the pharmacy.
The following medications are not covered under certain members' medical benefits, so you cannot buy and bill us for them:
Injectable specialty medication coverage (medical policy 071)
Requesting a formulary exception
Prescribers may request a formulary exception, when clinically appropriate, for a non-covered drug by using one of the methods listed below. We’ll notify you and the member of our decision.
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Use your practice’s electronic prior authorization (ePA) tools |
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Submit an eForm (commercial members):
Massachusetts Standard Form for Medication Prior Authorization Requests Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests |
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Fax (Medicare Advantage members): |
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Use your practice’s electronic prior authorization (ePA) tools |
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Submit an eForm (commercial members):
Massachusetts Standard Form for Medication Prior Authorization Request Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests |
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Fax (Medicare Advantage members): |
You can also call:
- Commercial, Medicare Advantage members: 1-800-366-7778
- Federal Employee Program members: 1-800-624-5060
"Managed not covered" medications for FEP Basic Option members
Certain medications for FEP Basic Option members are not covered, but may have another available option in the same therapeutic class. These are called "Managed Not Covered" medications. Basic Option members taking a "Managed Not Covered" drug should expect to pay the full cost of the prescription.
Get a list of Managed Not Covered medications on fepblue.org.
Coverage policies for medications that are new on the market
As new drugs are approved by the FDA, we have an evaluation process before adding the drug to our formulary.
We have an evaluation period before adding new, FDA-approved brand-name prescription drugs to our formulary after they receive FDA approval. During this evaluation period, the drug is not covered.
Our Pharmacy and Therapeutics Committee, which includes doctors and pharmacists from across Massachusetts, analyzes current literature to determine, among other things, the benefits and risks of each new drug. We will not impose this evaluation period for generic drugs.
If, following the evaluation, we decide that a drug will be excluded from the formulary, we will add that drug to our list of non-covered drugs.
Also, if a new drug is being evaluated and belongs to a therapeutic class that is managed through prior authorization, formulary management, or Quality Care Dosing, the established current therapeutic class criteria will be applied to the new drug. If the member does not meet the current therapeutic class criteria, you may request individual consideration.
During the time when a new drug is being evaluated, physicians can request a medical necessity exception for Members for whom no covered drug is clinically appropriate by following the steps outline above.
As new drugs are approved by the FDA, we have an evaluation process before adding the drug to our formulary as a specialty medication. During this evaluation period, the drug is not covered. Providers who wish to prescribe the non-covered medication must request formulary exception.
If your request for formulary exception is granted, the member must fill their prescription for this medication through a retail specialty pharmacy in our designated network.
If, after evaluation, we decide to add the medication to our formulary as a specialty medication, the member will be required to fill prescriptions for these medications through a retail specialty pharmacy in our designated network. Furthermore, if a new drug belongs to a therapeutic class that is managed by prior authorization, formulary management, or Quality Care Dosing, the established current therapeutic class criteria will be applied to the new drug. If the member does not meet the current therapeutic class criteria, you may request individual consideration.
