Pharmacy programs

This program allows you to get certain prescriptions used for chronic conditions delivered to your home. You can also get a 3-month supply of a prescription for the cost of a 1-month supply.

Learn more about your mail order pharmacy benefit.

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.

The Medical Drug Management Program (MDM) requires that some prescriber-administered drugs meet specific clinical conditions before a drug can be covered.  These drugs include injectable and intravenous drugs administered by your doctor in either their office, or other facility. We partner with Care Continuum (CCUM) to manage the provider-administered drug program.

If a drug falls into this group and may be medically necessary for you, your provider can submit a prior authorization (PA) request on your behalf to CCUM, or you can start a request for yourself by calling CCUM at 877-817-4042.

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.

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 877-417-1839.

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.

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: 844-319-7588
• Boston Medical Center Outpatient Pharmacy YACC: 617-414-4883

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.