Pharmacy Programs

We use a number of pharmacy programs to promote the safe and correct use of certain drugs. Drugs that belong to these programs have medical policies that must be met before we cover them. Here's a summary of our pharmacy programs:

Prior authorization program
Some drugs require your doctor or nurse to get prior authorization or prior approval from us before you can fill a prescription. If a drug falls into this group and may be medically necessary for you, your provider can submit a request to us to cover your prescription, or you can submit a request yourself by calling our partner, Express Scripts, at 1-877-417-1839.

Step therapy program
Step therapy requires that you try certain covered drugs before we will cover another similar drug. If you and your doctor feel that a covered drug is not appropriate to treat your medical condition, your doctor can submit a prior authorization request.

New-to-market medication program
We review new drugs for safety and efficacy before we add them to our List of Covered Drugs. If your doctor feels that a new-to-market drug is medically necessary for you, they can submit a prior authorization request.

Quantity limitation program
This program ensures the safe and appropriate use of some drugs. It involves covering a specific amount that can be dispensed (given by the pharmacist) at one time. If your doctor feels that an amount greater than the specified amount is medically necessary for you, they can submit a prior authorization request.

Mandatory generic substitution program
The U.S. Food and Drug Administration (FDA) decides when certain generic drugs are therapeutically equivalent (AB-rated) to their brand name alternatives. This means that an AB-rated generic drug is as effective as the brand-name drug, and you may be required to try the generic drug before the brand-name drug will be covered. If your doctor believes that the brand-name drug is medically necessary for you, they can submit a prior authorization request.

Specialty pharmacy program
This program requires some drugs to be supplied by a specialty pharmacy. These drugs include oral, injectable and intravenous drugs that are often used to treat chronic (ongoing) conditions and require the additional expertise and support of a specialty pharmacy. The Plan contracts with the following specialty pharmacies to provide these drugs:

• Cornerstone Health Solutions: 1-844-319-7588
• Boston Medical Center Outpatient Pharmacy YACC: 617-414-4883