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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 Call Pharmacy Operations at 1-800-366-7778

(For Federal Employee Program members, call CVS/Caremark at 1-877-727-3784.)

eForm (Commercial members)

Submit the appropriate eForm

Fax (Medicare members) Prior Authorization and Formulary Exception Request Form

Clinical criteria
To view clinical criteria used to make medical necessity decisions for coverage, use the links below.

  • Commercial and Medicare Advantage members with our pharmacy benefits:
    Refer to our medical policies.
  • Commercial members with the Standard Control with Advanced Control Specialty Formulary:
    Refer to clinical criteria.
Medications that require authorization when administered in a clinician's office or outpatient setting (medical benefits)

You can use Authorization Manager to request authorization for medications that you buy and bill us for, and that are administered in the office using the member’s medical benefits. Read our Quick Tip for more.

To use this eTool, log in and go to eTools>Authorization Manager.

Remember: before administering a medication to a patient in your office or outpatient setting, please check to see if the member has medical benefits for this service and determine whether prior authorization is required.

These medications are not covered by our commercial members’ medical benefits:

 Injectable specialty medication coverage (medical policy 071)

Note: Some employers may also customize coverage, so it’s important to check member benefits and eligibility.

Commercial members

Applies to:

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

Prior authorization is required for the 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.

Medicare Advantage members

We require prior authorization for the medications listed in our medical policy when administered using our Medicare Advantage members’ medical benefits. The requirement applies to the following outpatient settings:

  • A clinician’s or physician’s office
  • A home health care provider
  • A home infusion therapy provider
  • Outpatient hospital and dialysis settings.

 Medicare Advantage Part B Medical Utilization (MED UM) Policy 125

As additional drugs become available in these therapeutic classes, we may add drugs to this list.

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. 

Home infusion therapy

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