Your Pharmacy Coverage
The Value of Generic Medications
Search For Information On A Medication
Medications That Are Not Covered
Medications That Require Prior Authorization
Quality Care Dosing
Step Therapy
Mail Service Pharmacy
Frequently Asked Questions
Glossary Of Pharmacy Terms
Specialty Pharmacy Network


This list shows prescription medications that require your doctor to obtain authorization from us.

(s) indicates the pre-authorization is only required for Medex and Blue Care®65 members. 

You can download the Physician Request for Prior Authorization form (also called the Formulary Exception form), which requires Adobe® Acrobat® Reader

 
Medications that Require
Prior Authorization
Abstral
Actemra
Acthar
Actiq
Actonel
Adcirca
Addyi
Advair
Alecensa
Amevive
AMPHETAMINES / DEXTROAMPHETAMINES
Ampyra
Armodafinil
Astagraph XL (M)
Atelvia
Atomoxetine
Avodart
Azasan (M)
Azathioprine (M)
Belviq
Belviq XR
Bevespi AeroSphere
Binosto
Boniva
Botulinium Toxin
Buprenex
Capecitabine (M)
Capxib
Celebrex
Celecoxib
Cellcept (M)
Ceredase
Cerezyme
Cimzia
Cinqair
Cinryze
Cosentyx
Cotellic
Cyclosporine (M)
Cytoxan (M)
Daklinza
Desoxyn
DIABETES TREATMENTS
Dificid
Dulera
Dysport
Egrifta
Elidel
Enbrel
ENTERAL FORMULA
Entyvio
Envarsus XR (M)
Epclusa
ERYTHROPOIETIN
Exondys 51
FACTOR VIII, VIIIa, IX, XIII(Medical Benefit Only)
Farydak
Fentanyl Lozenge
Fentora
Forteo
Fosamax
Gengraf (M)
Grastek
GROWTH HORMONE
Harvoni
Hecoria (M)
Hetlioz
Humira
Hydroxyprogesterone
Ibandronate
Ibrance
Ilaris
Imogan (M)
Imovax (M)
Imuran (M)
Incruse Ellipta
Inflectra
INTERFERON (Alpha, Gamma)
IV Immunoglobulin (IVIG)
Jalyn
JOINT FLUID REPLACEMENT AGENTS
Juxtapid
Kalydeco
Kineret
Kisqali
Kisqali Femara
Kynamro
Lazanda
Lenvima
Lidoxib
LONG ACTING PAIN MEDICATIONS
Lynparza
Lyrica
Makena
Mekinist
Mirapex
Mirapex ER
Modafinil
Myalept
Mycophenolate (M)
Mycophenolic Acid (M)
Myfortic (M)
Neoral (M)
Nucala
NUTRTIONAL SUPPLEMENTS
Nuvigil
Olysio
Onsolis
Opdivo
OPHTHALMIC GLAUCOMA TREATMENTS
Oralair
Orencia
Orkambi
Otezla
OVERACTIVE BLADDER AGENTS
Praluent
Preservative-Free Morphine (Medical Benefit Only)
Prograf (M)
Prolastin
Prolia
Proscar
PROTON PUMP INHIBITORS (PPI)
Protopic
Provigil
Rabavert (M)
Ragwitek
Rapamune (M)
Raptiva
Reclast
Regranex
Remicade
Renflexis
Repatha
Requip
Requip XL
Respiratory Syncytial Virus IG/ Synagis(MED. ONLY)
Restasis
Revatio
Rituxan
Rydapt
Sandimmune (M)
Saxenda
SHORT ACTING PAIN MEDICATIONS
Sildenafil
Simponi
Simulect (M)
Sirolimus (M)
Solvaldi
Spinraza
Stelara
Strattera
Subsys
Symbicort
Tacrolimus (M)
Tacrolimus Topical
Tafinlar
Taltz
Technivie
TOPICAL RETINOIC ACID DERIVATIVES
TOPICAL TESTOSTERONE
Tudorza Pressair
Tysabri
Vectibix
Venclexta
Vepesid (M)
Victrelis
Viekira PAK
Xalkori
Xeljanz
Xeljanz XR
Xeloda (M)
Xeomin
Xgeva
Xiidra
Xolair
Zelboraf
Zenapax (M)
Zepatier
Zometa
Zortess (M)
Zydelig
Zykadia


Blue Cross and Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
® Registered Marks of the Blue Cross and Blue Shield Association.
© 2009 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.
Landmark Center, 401 Park Drive, Boston, MA 02215-3326 | 800-262-BLUE | TDD# 800-522-1254


Legal