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Pharmacy Medical Necessity Guidelines

We are introducing new formularies and Pharmacy Medical Necessity Guidelines, effective Jan. 1, 2023. The Pharmacy Medical Necessity Guidelines below detail coverage criteria. You may request authorization in one of the following ways: via PromptPA; use of electronic prior authorization (ePA) through EMR, CoverMyMeds, or Surescripts; or by FAX using the corresponding request forms (available prior to Jan. 1, 2023).

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Documents in this collection

Actemra (tocilizumab) Subcutaneous
Actimmune (interferon gamma-1b)
Adbry (tralokinumab-ldrm)
Antidepressants
Viibryd (vilazodone hydrochloride), Trintellix (vortioxetine), Fetzima (levomilnacipran hydrochloride), Forfivo XL (bupropion hydrochloride extended-release tablets), Pexeva (paroxetine mesylate)
Antineoplastics(Eff. through 4.30.23)
abiraterone, everolimus, everolimus disperz, Alecensa (alectinib), Alunbrig (brigatinib), Ayvakit (avapritinib), Balversa (erdafitinib), Bosulif (bosutinib), Braftovi (encorafenib), Brukinsa (zanubrutinib), Cabometyx (cabozantinib), Calquence (acalabrutinib), Caprelsa (vandetanib), Cometriq (cabozantinib), Copiktra (duvelisib), Cotellic (cobimetinib), Daurismo (glasdegib), Emcyt (estramustine), Erivedge (vismodegib), Erleada (apalutamide), Eulexin (flutamide), Exkivity (mobocertinib), Farydak (panobinostat), Fotivda (tivozanib), Gavreto (pralsetinib), Gilotrif (afatinib), Ibrance (palbociclib), Iclusig (ponatinib), Idhifa (enasidenib), Imbruvica (ibrutinib), Inlyta (axitinib), Inqovi (decitabine/cedazuridine), Inrebic (fedratinib), Jakafi (ruxolitinib), Kisqali/Kisqali PAK (ribociclib), Koselugo (selumetinib), Lenvima (lenvatinib), Lonsurf (trifluridine/tipiracil), Lorbrena (lorlatinib), Lumakras (sotorasib), Lynparza (olaparib), Mekinist (trametinib), Mektovi (binimetinib), Nexavar (sorafenib), Nerlynx (neratinib), Ninlaro (ixazomib), Nubeqa (darolutamide), Odomzo (sonidegib), Onureg (azacytidine), Orgovyx (relugolix), Pemazyre (pemigatinib), Piqray (alpelisib), Pomalyst (pomalidomide), Qinlock (ripretinib), Retevmo (selpercatinib), Revlimid (lenalidomide), Rozlytrek (entrectinib), Rubraca (rucaparib), Rydapt (midostaurin), Scemblix (asciminib), Stivarga (regorafenib), Tabrecta (capmatinib), Tafinlar (dabrafenib), Tagrisso (osimertinib), Talzenna (talazoparib), Tazverik (tazemetostat), Tepmetko (tepotinib), Tibsovo (ivosidenib), , Tukysa (tucatinib), Turalio (pexidartinib), Truseltiq (infigratinib), Ukoniq (umbralisib), Venclexta (venetoclax), Verzenio (abemaciclib), Vitrakvi (larotrectinib), Vizimpro (dacomitinib), Vonjo (pacritinib), Welireg (belzutifan), Xalkori (crizotinib), Xospata (gilteritinib Xpovio (selinexor), Xtandi (enzalutamide), Yonsa (abiraterone acetate), Zejula (niraparib), Zelboraf (vemurafenib), Zydelig (idelalisib), Zykadia (ceritinib)
Antineoplastics(Eff. beginning 5.1.23)
abiraterone, everolimus, everolimus disperz, Alecensa (alectinib), Alunbrig (brigatinib), Ayvakit (avapritinib), Balversa (erdafitinib), Bosulif (bosutinib), Braftovi (encorafenib), Brukinsa (zanubrutinib), Cabometyx (cabozantinib), Calquence (acalabrutinib), Caprelsa (vandetanib), Cometriq (cabozantinib), Copiktra (duvelisib), Cotellic (cobimetinib), Daurismo (glasdegib), Emcyt (estramustine), Erivedge (vismodegib), Erleada (apalutamide), Eulexin (flutamide), Exkivity (mobocertinib), Farydak (panobinostat), Fotivda (tivozanib), Gavreto (pralsetinib), Gilotrif (afatinib), Ibrance (palbociclib), Iclusig (ponatinib), Idhifa (enasidenib), Imbruvica (ibrutinib), Inlyta (axitinib), Inqovi (decitabine/cedazuridine), Inrebic (fedratinib), Jakafi (ruxolitinib), Kisqali/Kisqali PAK (ribociclib), Koselugo (selumetinib), Lenvima (lenvatinib), Lonsurf (trifluridine/tipiracil), Lorbrena (lorlatinib), Lumakras (sotorasib), Lynparza (olaparib), Mekinist (trametinib), Mektovi (binimetinib), Nexavar (sorafenib), Nerlynx (neratinib), Ninlaro (ixazomib), Nubeqa (darolutamide), Odomzo (sonidegib), Onureg (azacytidine), Orgovyx (relugolix), Pemazyre (pemigatinib), Piqray (alpelisib), Pomalyst (pomalidomide), Qinlock (ripretinib), Retevmo (selpercatinib), Revlimid (lenalidomide), Rozlytrek (entrectinib), Rubraca (rucaparib), Rydapt (midostaurin), Scemblix (asciminib), Stivarga (regorafenib), Tabrecta (capmatinib), Tafinlar (dabrafenib), Tagrisso (osimertinib), Talzenna (talazoparib), Tazverik (tazemetostat), Tepmetko (tepotinib), Tibsovo (ivosidenib), , Tukysa (tucatinib), Turalio (pexidartinib), Truseltiq (infigratinib), Ukoniq (umbralisib), Venclexta (venetoclax), Verzenio (abemaciclib), Vitrakvi (larotrectinib), Vizimpro (dacomitinib), Vonjo (pacritinib), Welireg (belzutifan), Xalkori (crizotinib), Xospata (gilteritinib Xpovio (selinexor), Xtandi (enzalutamide), Yonsa (abiraterone acetate), Zejula (niraparib), Zelboraf (vemurafenib), Zydelig (idelalisib), Zykadia (ceritinib)
Antipsychotics Step Therapy Programs
Rexulti (brexpiprazole), Vraylar (cariprazine), Paliperidone extended-release tablets
Antiseizure Medications
Epidiolex (cannabidiol), Nazyzilam (midazolam), Valtoco (diazepam), Ztalmy (ganaxolone)
Arcalyst (rilonacept)
Asmanex Step Therapy
Asmanex (mometasone furoate)
Attention Deficit Hyperactivity Disorder Drugs
Amphetamine (Adzenys XR-ODT, Dyanavel XR, Evekeo, Evekeo ODT), Dexmethylphenidate (Focalin, Focalin XR), Dextroamphetamine (Dexedrine, ProCentra, Zenzedi), Lisdexamfetamine (Vyvanse), Methamphetamine (Desoxyn), Methylphenidate (Adhansia XR, Aptensio XR, Concerta, Cotempla XR-ODT, Daytrana, Jornay PM, Methylin, QuilliChew ER, Quillivant XR, Relexxii, Ritalin, Ritalin LA), Serdexmethylphenidate and Dexmethylphenidate (Azstarys), Qelbree (viloxazine)
Benlysta (belimumab) Subcutaneous
Bepreve (bepotastine)
Besremi (ropeginterferon alfa-2b-njft)
Bronchitol (mannitol)
Bylvay (odevixibat)
Cablivi (caplacizumab-yhdp)
Camzyos (mavacamten)
Cerdelga (eliglustat)
Chelating and Reducing Agents
penicillamine, clovique, trientine, Thiola (tiopronin)
Cialis for Benign Prostatic Hypertrophy (BPH)
Cialis (tadalafil) 2.5 mg and 5 mg
Cibinqo (abrocitinib)(Eff. through 4.30.23)
Cibinqo (abrocitinib)(Eff. beginning 5.1.23)
Cimzia (certolizumab pegol)
Compound Medications
Cosentyx (secukinumab)
Cushing’s Disease Agents
Isturisa (osilodrostat), Korlym (mifepristone), Recorlev (levoketoconazole)
Cystic Fibrosis Medications
Kalydeco (ivacaftor), Orkambi (lumacaftor/ivacaftor), Symdeko (tezacaftor/ivacaftor), Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor)
Daraprim (pyrimethamine)
Denavir (penciclovir) cream

Requesting Authorization

Quickly and easily request authorization one of 4 ways!

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Medication Request Forms

Massachusetts (MA providers only)
New Hampshire (NH providers only)
States other than MA & NH
MA Hepatitis C (MA providers only)
MA Oncology (MA providers only)
MA Synagis (MA providers only)

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