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Prior Authorization

Medication management

With input from community physicians, specialty societies, and our Pharmacy & Therapeutics Committee, which includes community physicians and pharmacists from across the state, we design programs to help keep prescription drug coverage affordable.

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Medications that require prior authorization (pharmacy benefits)

We encourage you to use our medication look-up tools to determine whether prior authorization is required.

If prior authorization is required, you can request it by:

Phone Clinical Pharmacy Operations at 1-800-366-7778
eForm (Commercial members)

Submit the appropriate eForm

Fax (Medicare members) Prior Authorization and Formulary Exception Request Form
Call (Federal Employee Program members) CVS/Caremark at 1-877-727-3784
(available 7 am - 9 pm, Monday through Friday, Eastern Time)
Medications that require authorization when administered in a clinician's office or outpatient setting (medical benefits)

Before administering a medication to a patient in your office or outpatient setting (using the member’s medical benefits), please check to see if the member has medical benefits for this service and determine whether prior authorization is required.

Commercial HMO, POS*, and Access Blue members who have a Massachusetts-based primary care provider

Prior authorization is required for these medications listed in these policies when administered in a clinician’s office or outpatient setting and billed under the member’s medical benefits.

 Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033)
 Medical Benefit Prior Authorization Medication List (034)

To request prior authorization for these medications, please submit the: Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or contact Clinical Pharmacy Operations.

To request prior authorization for these medications, please submit the: Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or contact Clinical Pharmacy Operations.

*Blue Choice members using their self-referred benefit do not need to get prior authorization.

Other medications that require prior authorization

Please refer to our Medical Policies for other medications that may require prior authorization. For certain high-cost medications or therapies, we have a specific fax number listed in the medical policy to expedite your request.

Home infusion therapy

Home infusion therapy requires an authorization, regardless of the medication administered.

Medications that aren't covered by medical benefits

 Injectable specialty medication coverage (medical policy 071)

Medical benefits for medications for Federal Employee Program (FEP) members

Check medical policies on fepblue.org to see if an authorization is required for the medication you plan to administer using the member’s medical benefits.