 |
Medical- Asthma Monoclonal Antibodies (Policy MA9.109), Effective 05/01/2022
|
Mass Health |
 |
Medical- Infliximab Products (Policy MA9.123), Effective 05/01/2022
|
Mass Health |
 |
Medical- Complement Inhibitors (Policy MA9.134), Effective 05/01/2022
|
Mass Health |
 |
Medical- Erythropoiesis-Stimulating Agents (Policy MA9.609), Effective 05/01/2022
|
Mass Health |
 |
Medical- Filgrastim Products (Policy MA9.631), Effective 05/01/2022
|
Mass Health |
 |
Medical- Rituximab (Policy MA9.704), Effective 05/01/2022
|
Mass Health |
 |
Age & Quantity Limitation Program Policy (Policy MA9.050), Effective 01/01/2022
|
Mass Health |
 |
Non-Formulary Exceptions (Policy MA9.051), Effective 01/01/2022
|
Mass Health |
 |
Prescription Compounds (Policy MA9.054), Effective 01/01/2022
|
Mass Health |
 |
Hereditary Angioedema (Policy MA9.101), Effective 01/01/2022
|
Mass Health |
 |
Topical Immunomodulators (Policy MA9.103), Effective 01/01/2022
|
Mass Health |
 |
Sublingual Immunotherapy (SLIT) Medications (Policy MA9.104), Effective 01/01/2022
|
Mass Health |
 |
Esbriet (Policy MA9.105), Effective 01/01/2022
|
Mass Health |
 |
Nplate (Policy MA9.106), Effective 01/01/2022
|
Mass Health |
 |
Promacta (Policy MA9.107), Effective 01/01/2022
|
Mass Health |
 |
Kyrstexxa (Pegloticase) (Policy MA9.108), Effective 01/01/2022
|
Mass Health |
 |
Immune Globulin (Policy MA9.110), Effective 01/01/2022
|
Mass Health |
 |
Daliresp (Policy MA9.111), Effective 01/01/2022
|
Mass Health |
 |
Acthar H.P. Gel (Policy MA9.112), Effective 01/01/2022
|
Mass Health |
 |
Benlysta (Belimumab) (Policy MA9.115), Effective 01/01/2022
|
Mass Health |
 |
Entyvio (Policy MA9.120), Effective 01/01/2022
|
Mass Health |
 |
Infliximab Products (Policy MA9.123), Effective 01/01/2022
|
Mass Health |
 |
Methotrexate (Policy MA9.125), Effective 01/01/2022
|
Mass Health |
 |
Ofev (Policy MA9.133), Effective 01/01/2021
|
Mass Health |
 |
Ofev (Policy MA9.133), Effective 01/01/2022
|
Mass Health |
 |
Complement Inhibitors (Policy MA9.134), Effective 03/01/2022
|
Mass Health |
 |
Lambert Eaton Myasthenic Syndrome (Policy MA9.135), Effective 01/01/2022
|
Mass Health |
 |
Tavalisse (Policy MA9.136), Effective 01/01/2022
|
Mass Health |
 |
Step Therapy Policy - Gout (Policy MA9.137), Effective 01/01/2022
|
Mass Health |
 |
Step Therapy Policy - Pulmonary Agents (Policy MA9.138), Effective 01/01/2022
|
Mass Health |
 |
Immune Suppressants - Topical - Unified Formulary (Policy MA9.139), Effective 01/01/2022
|
Mass Health |
 |
Respiratory Agents - Unified Formulary (Policy MA9.141), Effective 01/01/2022
|
Mass Health |
 |
Step Therapy Policy - Oral and Nasal Allergy Agents (Policy MA9.142), Effective 01/01/2021
|
Mass Health |
 |
Step Therapy Policy - Oral and Nasal Allergy Agents (Policy MA9.142), Effective 01/01/2022
|
Mass Health |
 |
Asthma and Allergy Monoclonal Antibodies- Unified Formulary (Policy MA9.143), Effective 09/01/2021
|
Mass Health |
 |
Asthma and Allergy Monoclonal Antibodies - Unified Formulary (Policy MA9.143), Effective 01/01/2022
|
Mass Health |
 |
Targeted Immunomodulators- United Formulary (Policy MA9.144), Effective 09/01/2021
|
Mass Health |
 |
Targeted Immunomodulators (TIMs) - Unified Formulary (Policy MA9.144), Effective 07/01/2021
|
Mass Health |
 |
Arcalyst and Ilaris - Unified Formulary (Policy MA9.145), Effective 01/01/2022
|
Mass Health |
 |
Levalbuterol Nebulizer Solution (Policy MA9.147), Effective 01/01/2022
|
Mass Health |
 |
Cystic Fibrosis-CFTR Modulators- Unified Formulary (Policy MA9.148), Effective 01/01/2022
|
Mass Health |
 |
Lupkynis (Policy MA9.153), Effective 01/01/2022
|
Mass Health |
 |
Nuedexta (Policy MA9.200), Effective 06/01/2021
|
Mass Health |
 |
Diacomit (Policy MA9.201), Effective 01/01/2021
|
Mass Health |
 |
Diacomit (Policy MA9.201), Effective 06/01/2021
|
Mass Health |
 |
Savella (Policy MA9.202), Effective 06/01/2021
|
Mass Health |
 |
Cuvposa (Glycopyrrolate) (Policy MA9.203), Effective 06/01/2021
|
Mass Health |
 |
VMAT 2 Inhibitors (Policy MA9.204), Effective 06/01/2021
|
Mass Health |
 |
Calcitonin Gene-Related Peptide Antagonist (CGRP) (Policy MA9.205), Effective 06/01/2021
|
Mass Health |
 |
Pregabalin (Policy MA9.206), Effective 01/01/2021
|
Mass Health |
 |
Tramadol ER (Policy MA9.207), Effective 06/01/2021
|
Mass Health |
 |
Narcolepsy (Policy MA9.208), Effective 06/01/2021
|
Mass Health |
 |
Botox (Policy MA9.209), Effective 06/01/2021
|
Mass Health |
 |
Opioids (Policy MA9.210), Effective 06/01/2021
|
Mass Health |
 |
Insomnia Agents (Policy MA9.211), Effective 06/01/2021
|
Mass Health |
 |
Multiple Sclerosis (Policy MA9.212), Effective 01/01/2022
|
Mass Health |
 |
Inbrija (Policy MA9.213), Effective 06/01/2021
|
Mass Health |
 |
Step Therapy Policy - Anticonvulsant Agents (Policy MA9.214), Effective 07/01/2021
|
Mass Health |
 |
Step Therapy Policy - Migraine Agents (Policy MA9.215), Effective 06/01/2021
|
Mass Health |
 |
Step Therapy Policy - Anti-Parkinson Agents (Policy MA9.217), Effective 06/01/2021
|
Mass Health |
 |
Step Therapy Policy - NSAIDS (Policy MA9.218), Effective 06/01/2021
|
Mass Health |
 |
Multiple Sclerosis - Unified Formulary (Policy MA9.219), Effective 01/01/2022
|
Mass Health |
 |
Calcitonin-Gene Related Peptide (CGRP) Inhibitors - Unified Formulary (Policy MA9.220), Effective 06/01/2021
|
Mass Health |
 |
Epidiolex (Policy MA9.222), Effective 06/01/2021
|
Mass Health |
 |
Fintepla (Policy MA9.224), Effective 06/01/2021
|
Mass Health |
 |
Kynmobi (Policy MA9.225), Effective 06/01/2021
|
Mass Health |
 |
Valtoco-Nayzilam (Policy MA9.226), Effective 06/01/2021
|
Mass Health |
 |
Amyloidosis Therapies - Unified Formulary (Policy MA9.227), Effective 01/01/2022
|
Mass Health |
 |
Spinraza (Policy MA9.229), Effective 09/01/2021
|
Mass Health |
 |
Anticonvulsants (Policy MA9.230), Effective 09/01/2021
|
Mass Health |
 |
Anticonvulsants - Unified Formulary (Policy MA9.230), Effective 07/01/2021
|
Mass Health |
 |
Dojolvi (Policy MA9.231), Effective 09/01/2021
|
Mass Health |
 |
Evrysdi (Policy MA9.232), Effective 09/01/2021
|
Mass Health |
 |
Isturisa (Policy MA9.233), Effective 09/01/2021
|
Mass Health |
 |
Zeposia -United Formulary (Policy MA9.234), Effective 01/01/2022
|
Mass Health |
 |
Osphena (Policy MA9.300), Effective 03/01/2022
|
Mass Health |
 |
Brineura (Policy MA9.301), Effective 01/01/2021
|
Mass Health |
 |
Brineura (Policy MA9.301), Effective 09/01/2021
|
Mass Health |
 |
Duchenne Muscular Dystrophy Agents (Policy MA9.302), Effective 01/01/2021
|
Mass Health |
 |
Duchenne Muscular Dystrophy (Policy MA9.302), Effective 09/01/2021
|
Mass Health |
 |
Korlym (Policy MA9.303), Effective 01/01/2021
|
Mass Health |
 |
Korlym (Policy MA9.303), Effective 09/01/2021
|
Mass Health |
 |
Egrifta (Policy MA9.304), Effective 01/01/2021
|
Mass Health |
 |
Urea Cycle Disorder Agents (Policy MA9.305), Effective 01/01/2021
|
Mass Health |
 |
Urea Cycle Disorder Agents (Policy MA9.305), Effective 09/01/2021
|
Mass Health |
 |
Signifor (Policy MA9.306), Effective 01/01/2021
|
Mass Health |
 |
Myalept (Policy MA9.307), Effective 01/01/2021
|
Mass Health |
 |
Cholbam (Policy MA9.308), Effective 03/01/2022
|
Mass Health |
 |
Natpara (Policy MA9.309), Effective 01/01/2021
|
Mass Health |
 |
Natpara (Policy MA9.309), Effective 09/01/2021
|
Mass Health |
 |
Trientine (Syprine) (Policy MA9.310), Effective 01/01/2021
|
Mass Health |
 |
Kanuma (Policy MA9.311), Effective 01/01/2021
|
Mass Health |
 |
Kanuma (Policy MA9.311), Effective 09/01/2021
|
Mass Health |
 |
Strensiq (Policy MA9.312), Effective 01/01/2021
|
Mass Health |
 |
Strensiq (Policy MA9.312), Effective 09/01/2021
|
Mass Health |
 |
Cerdelga (Policy MA9.313), Effective 01/01/2021
|
Mass Health |
 |
Rayaldee (Policy MA9.314), Effective 01/01/2021
|
Mass Health |
 |
Rayaldee (Policy MA9.314), Effective 09/01/2021
|
Mass Health |
 |
Spinraza (Policy MA9.315), Effective 01/01/2021
|
Mass Health |
 |
Mepsevii (Policy MA9.316), Effective 01/01/2021
|
Mass Health |
 |
Mepsevii (Policy MA9.316), Effective 09/01/2021
|
Mass Health |
 |
Increlex (Policy MA9.317), Effective 01/01/2021
|
Mass Health |
 |
Increlex (Policy MA9.317), Effective 09/01/2021
|
Mass Health |
 |
Metabolic Bone Disease Agents (Policy MA9.318), Effective 01/01/2021
|
Mass Health |
 |
Metabolic Bone Disease Agents (Policy MA9.318), Effective 09/01/2021
|
Mass Health |
 |
Samsca (Policy MA9.319), Effective 01/01/2021
|
Mass Health |
 |
Samsca/Tolvaptan (Policy MA9.319), Effective 09/01/2021
|
Mass Health |
 |
Vyndaqel, Vyndamax (Policy MA9.323), Effective 01/01/2021
|
Mass Health |
 |
Crysvita (Policy MA9.324), Effective 01/01/2021
|
Mass Health |
 |
Crysvita (Policy MA9.324), Effective 09/01/2021
|
Mass Health |
 |
Step Therapy Policy - Bisphosphonates (Policy MA9.329), Effective 01/01/2021
|
Mass Health |
 |
Step Therapy Bisphosphonates (Policy MA9.329), Effective 09/01/2021
|
Mass Health |
 |
Spinal Muscular Atrophy (SMA) Agents - Unified Formulary (Policy MA9.331), Effective 01/01/2021
|
Mass Health |
 |
Spinal Muscular Atrophy (SMA) Agents (Policy MA9.331), Effective 09/01/2021
|
Mass Health |
 |
Antidiabetic Agents - Unified Formulary (Policy MA9.332), Effective 07/01/2021
|
Mass Health |
 |
Antidiabetic Agents - United Formulary (Policy MA9.332), Effective 01/01/2022
|
Mass Health |
 |
Glucagon Products - Unified Formulary (Policy MA9.333), Effective 09/01/2021
|
Mass Health |
 |
Growth Hormone Agents - Unified Formulary (Policy MA9.334), Effective 01/01/2022
|
Mass Health |
 |
Insulin Products - Unified Formulary (Policy MA9.335), Effective 01/01/2022
|
Mass Health |
 |
Diabetic Testing Supplies - United Formulary (Policy MA9.336), Effective 07/01/2021
|
Mass Health |
 |
Diabetic Testing Supplies- United Formulary (Policy MA9.336), Effective 09/01/2021
|
Mass Health |
 |
Continuous Glucose Monitoring - Unified Formulary (Policy MA9.337), Effective 01/01/2022
|
Mass Health |
 |
Continuous Glucose Monitoring- United Formulary (Policy MA9.337), Effective 07/01/2021
|
Mass Health |
 |
Givlaari - Unified Formulary (Policy MA9.338), Effective 07/01/2021
|
Mass Health |
 |
Givlaari- United Formulary (Policy MA9.338), Effective 09/01/2021
|
Mass Health |
 |
Continuous Subcutaneous Insulin Infusion- United Formulary (Policy MA9.339), Effective 09/01/2021
|
Mass Health |
 |
Continuous Subcutaneous Insulin Infusion - Unified Formulary (Policy MA9.339), Effective 01/01/2022
|
Mass Health |
 |
Fabrazyme (Policy MA9.341), Effective 09/01/2021
|
Mass Health |
 |
Pyrimethamine (Daraprim) (Policy MA9.401), Effective 06/01/2021
|
Mass Health |
 |
Impavido (Policy MA9.402), Effective 06/01/2021
|
Mass Health |
 |
Systemic Antibiotics (Policy MA9.403), Effective 06/01/2021
|
Mass Health |
 |
Synagis (Policy MA9.405), Effective 06/01/2021
|
Mass Health |
 |
Antifungal Agents (Policy MA9.406), Effective 06/01/2021
|
Mass Health |
 |
Step Therapy Policy - Pediculicides (Policy MA9.408), Effective 06/01/2021
|
Mass Health |
 |
Hepatitis Antiviral Agents- United Formulary (Policy MA9.409), Effective 09/01/2021
|
Mass Health |
 |
Hepatitis Antiviral Agents - Unified Formulary (Policy MA9.409), Effective 06/01/2021
|
Mass Health |
 |
Pediatric Behavioral Health Medication Initiative (Policy MA9.500), Effective 06/01/2021
|
Mass Health |
 |
Lucemyra (Policy MA9.501), Effective 06/01/2021
|
Mass Health |
 |
Antidepressants (Policy MA9.502), Effective 06/01/2021
|
Mass Health |
 |
Antipsychotics (Policy MA9.503), Effective 09/01/2021
|
Mass Health |
 |
Buprenorphine and Naloxone Products (Policy MA9.504), Effective 06/01/2021
|
Mass Health |
 |
Clonidine ER (Policy MA9.505), Effective 01/01/2022
|
Mass Health |
 |
Step Therapy Policy - Antidepressant and Antipsychotic Agents (Policy MA9.506), Effective 06/01/2021
|
Mass Health |
 |
Antipsychotics- United Formulary (Policy MA9.507), Effective 09/01/2021
|
Mass Health |
 |
Antipsychotics - Unified Formulary (Policy MA9.507), Effective 01/01/2022
|
Mass Health |
 |
Cerebral Stimulants and ADHD Medications - Unified Formulary (Policy MA9.508), Effective 01/01/2022
|
Mass Health |
 |
Opioid Dependence and Reversal Agents- United Formulary (Policy MA9.509), Effective 09/01/2021
|
Mass Health |
 |
Opioid Dependence - Unified Formulary (Policy MA9.509), Effective 01/01/2022
|
Mass Health |
 |
Pulmonary Hypertension (Policy MA9.600), Effective 3/01/2022
|
Mass Health |
 |
ACEIs and ARBs (Policy MA9.601), Effective 03/01/2022
|
Mass Health |
 |
Beta Blockerss (Policy MA9.602), Effective 3/01/2022
|
Mass Health |
 |
Homozygous Familial Hypercholesterolemia (Policy MA9.603), Effective 03/01/2022
|
Mass Health |
 |
Droxidopa (Policy MA9.604), Effective 03/01/2022
|
Mass Health |
 |
PCSK9 Inhibitors (Policy MA9.605), Effective 03/01/2022
|
Mass Health |
 |
Entresto (Policy MA9.606), Effective 01/01/2021
|
Mass Health |
 |
Omega Fatty Acids (Policy MA9.607), Effective 03/01/2022
|
Mass Health |
 |
Ranolazine ER (Policy MA9.608), Effective 03/01/2022
|
Mass Health |
 |
Blood Clotting Disorder Medications (Policy MA9.610), Effective 03/01/2022
|
Mass Health |
 |
Adakveo (Policy MA9.611), Effective 03/01/2022
|
Mass Health |
 |
Oxbryta (Policy MA9.612), Effective 03/01/2022
|
Mass Health |
 |
Reblozyl (Policy MA9.613), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Antihypertensive Agents (Policy MA9.615), Effective 03/01/2022
|
Mass Health |
 |
Erythropoiesis Stimulating Agents (ESAs) - Unified Formulary (Policy MA9.617), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Anti-Platelet Agents (Policy MA9.618), Effective 03/01/2022
|
Mass Health |
 |
Anticoagulants- United Formulary (Policy MA9.619), Effective 01/01/2022
|
Mass Health |
 |
Granulocyte Stimulating Agents - Unified Formulary (Policy MA9.621), Effective 03/01/2022
|
Mass Health |
 |
Iron Chelating Agents (Policy MA9.625), Effective 03/01/2022
|
Mass Health |
 |
Sapropterin (Policy MA9.626), Effective 09/01/2021
|
Mass Health |
 |
Verquvo (Policy MA9.630), Effective 03/01/2022
|
Mass Health |
 |
Antineoplastic Agents (Policy MA9.700), Effective 01/01/2021
|
Mass Health |
 |
Antineoplastic Agents (Policy MA9.700), Effective 01/01/2022
|
Mass Health |
 |
Xermelo (Policy MA9.701), Effective 01/01/2021
|
Mass Health |
 |
Xermelo (Policy MA9.701), Effective 09/01/2021
|
Mass Health |
 |
Mozobil (Policy MA9.702), Effective 01/01/2021
|
Mass Health |
 |
Mozobil (Policy MA9.702), Effective 09/01/2021
|
Mass Health |
 |
GnRH Agents (Policy MA9.703), Effective 03/01/2022
|
Mass Health |
 |
Rituximab (Policy MA9.704), Effective 01/01/2021
|
Mass Health |
 |
Rituximab (Policy MA9.704), Effective 09/01/2021
|
Mass Health |
 |
Tepezza (Policy MA9.705), Effective 01/01/2021
|
Mass Health |
 |
Tepezza (Policy MA9.705), Effective 09/01/2021
|
Mass Health |
 |
Enhertu (Policy MA9.706), Effective 01/01/2021
|
Mass Health |
 |
Enhertu (Policy MA9.706), Effective 09/01/2021
|
Mass Health |
 |
Padcev (Policy MA9.707), Effective 01/01/2021
|
Mass Health |
 |
Padcev (Policy MA9.707), Effective 09/01/2021
|
Mass Health |
 |
Breast Cancer Therapies - Unified Formulary (Policy MA9.708), Effective 01/01/2021
|
Mass Health |
 |
Breast Cancer Therapies- United Formulary (Policy MA9.708), Effective 01/01/2022
|
Mass Health |
 |
Chronic Myelogenous Leukemia (CML) Agents - Unified Formulary (Policy MA9.709), Effective 01/20/2021
|
Mass Health |
 |
Colorectal Cancer Agents - Unified Formulary (Policy MA9.710), Effective 01/01/2021
|
Mass Health |
 |
Colorectal Cancer Agents- United Formulary (Policy MA9.710), Effective 09/01/2021
|
Mass Health |
 |
Kinase Inhibitors- United Formulary (Policy MA9.711), Effective 09/01/2021
|
Mass Health |
 |
Kinase Inhibitors - Unified Formulary (Policy MA9.711), Effective 01/01/2022
|
Mass Health |
 |
Lung Cancer Agents- United Formulary (Policy MA9.712), Effective 09/01/2021
|
Mass Health |
 |
Lung Cancer Agents - Unified Formulary (Policy MA9.712), Effective 01/01/2022
|
Mass Health |
 |
Lymphoma and Leukemia Agents - Unified Formulary (Policy MA9.713), Effective 01/01/2021
|
Mass Health |
 |
Lymphoma and Leukemia Agents (Policy MA9.713), Effective 09/01/2021
|
Mass Health |
 |
Melanoma Agents - Unified Formulary (Policy MA9.714), Effective 01/01/2022
|
Mass Health |
 |
Melanoma Agents (Policy MA9.714), Effective 09/01/2021
|
Mass Health |
 |
Medullary Thyroid Cancer Agents - Unified Formulary (Policy MA9.715), Effective 01/01/2021
|
Mass Health |
 |
Medullary Thyroid Cancer Agents- United Formulary (Policy MA9.715), Effective 09/01/2021
|
Mass Health |
 |
Neurotrophic Receptor Tyrosine Kinase Inhibitors (NRTK) Inhibitors - Unified Formulary (Policy MA9.716), Effective 01/01/2021
|
Mass Health |
 |
Turalio - Unified Formulary (Policy MA9.717), Effective 01/01/2021
|
Mass Health |
 |
Turalio- United Formulary (Policy MA9.717), Effective 09/01/2021
|
Mass Health |
 |
JAK Inhibitors- United Formulary (Policy MA9.718), Effective 09/01/2021
|
Mass Health |
 |
JAK Inhibitors - Unified Formulary (Policy MA9.718), Effective 01/01/2022
|
Mass Health |
 |
Gavreto (Policy MA9.719), Effective 09/01/2021
|
Mass Health |
 |
Inqovi (Policy MA9.720), Effective 09/01/2021
|
Mass Health |
 |
Monjuvi (Policy MA9.721), Effective 09/01/2021
|
Mass Health |
 |
Onureg (Policy MA9.722), Effective 09/01/2021
|
Mass Health |
 |
Pepaxto/Blenrep (Policy MA9.723), Effective 09/01/2021
|
Mass Health |
 |
Uplinza (Policy MA9.725), Effective 09/01/2021
|
Mass Health |
 |
Xpovio (Policy MA9.726), Effective 09/01/2021
|
Mass Health |
 |
Ayvakit (Policy MA9.727), Effective 09/01/2021
|
Mass Health |
 |
Jelmyto (Policy MA9.731), Effective 09/01/2021
|
Mass Health |
 |
Pemazyre (Policy MA9.732), Effective 09/01/2021
|
Mass Health |
 |
Qinlock (Policy MA9.733), Effective 09/01/2021
|
Mass Health |
 |
Trodelvy (Policy MA9.735), Effective 09/01/2021
|
Mass Health |
 |
Zepzelca (Policy MA9.737), Effective 09/01/2021
|
Mass Health |
 |
Hydroxyprogesterone Caproate (Policy MA9.800), Effective 03/01/2022
|
Mass Health |
 |
Tranexamic Acid (Policy MA9.801), Effective 03/01/2022
|
Mass Health |
 |
Gattex (Policy MA9.802), Effective 03/01/2022
|
Mass Health |
 |
Ocaliva (Policy MA9.803), Effective 03/01/2022
|
Mass Health |
 |
Gastrointestinal Agents (Policy MA9.804), Effective 03/01/2022
|
Mass Health |
 |
Benign Prostatic Hyperplasia (BPH) Medications (Policy MA9.805), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Proton Pump Inhibitors (Policy MA9.806), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Urinary Antispasmodic Agents (Policy MA9.807), Effective 03/01/2022
|
Mass Health |
 |
Phexxi (Policy MA9.811), Effective 03/01/2022
|
Mass Health |
 |
Oriahnn and Myfembree (Policy MA9.812), Effective 03/01/2022
|
Mass Health |
 |
Bylvay (Policy MA9.814), Effective 03/01/2022
|
Mass Health |
 |
Ophthalmic Antibodies (Policy MA9.901), Effective 03/01/2022
|
Mass Health |
 |
Restasis, Xiidra (Policy MA9.902), Effective 03/01/2022
|
Mass Health |
 |
Mytesi (Policy MA9.903), Effective 030/01/2022
|
Mass Health |
 |
Luxterna (Policy MA9.904), Effective 03/01/2022
|
Mass Health |
 |
Antiemetics (Policy MA9.905), Effective 03/01/2022
|
Mass Health |
 |
Topical Medications (MISC) (Policy MA9.906), Effective 03/01/2022
|
Mass Health |
 |
Anabolic Steroids - Anadrol, Oxandrolone (Policy MA9.907), Effective 03/01/2022
|
Mass Health |
 |
Acne and Rosacea Agents (Policy MA9.908), Effective 03/01/2022
|
Mass Health |
 |
Viscosupplements (Policy MA9.909), Effective 03/01/2022
|
Mass Health |
 |
Bile Acid Sequestrants (Policy MA9.910), Effective 03/01/2022
|
Mass Health |
 |
Xiaflex (Policy MA9.911), Effective 03/01/2022
|
Mass Health |
 |
Rhopressa (Netrasudil) (Policy MA9.912), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Glaucoma (Policy MA9.913), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Miscellaneous Ophthalmic Policy (Policy MA9.915), Effective 03/01/2022
|
Mass Health |
 |
Step Therapy Policy - Topical Acne Agents (Policy MA9.916), Effective 03/01/2022
|
Mass Health |
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Step Therapy Policy - Topical Lidocaine (Policy MA9.917), Effective 03/01/2022
|
Mass Health |
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Step Therapy Policy - Topical Steroids (Policy MA9.918), Effective 03/01/2022
|
Mass Health |
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Vyndaqel, Vyndamax (Policy MA9.323), Effective 09/01/2021
|
Mass Health |
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Chronic Myelogenous Leukemia (CML) Agents- United Formulary (Policy MA9.709), Effective 09/01/2021
|
Mass Health |
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Neurotrophic Receptor Tyrosine Kinase (NRTK) Inhibitors- United Formulary (Policy MA9.716), Effective 09/01/2021
|
Mass Health |
 |
QHP9.212_Multiple-Sclerosis_Rev2021
|
Mass Health |
 |
Zokinvy (Policy MA9.340), Effective 09/01/2021
|
Mass Health |
 |
Medical- Asthma Monoclonal Antibodies (Policy QHP9.109), Effective 05/01/2022
|
Qualified Health Plan |
 |
Medical- Infliximab Products (Policy QHP9.123), Effective 05/01/2022
|
Qualified Health Plan |
 |
Medical- Complement Inhibitors (Policy QHP9.134), Effective 05/01/2022
|
Qualified Health Plan |
 |
Medical- Erythropoiesis-Stimulating Agents (Policy QHP9.609), Effective 05/01/2022
|
Qualified Health Plan |
 |
Medical- Filgrastim Products (Policy QHP9.631), Effective 05/01/2022
|
Qualified Health Plan |
 |
Medical- Rituximab (Policy QHP9.704), Effective 05/01/2022
|
Qualified Health Plan |
 |
Age & Quantity Limitation Program Policy (Policy QHP9.050), Effective 01/01/2022
|
Qualified Health Plan |
 |
Non-Formulary Exceptions (Policy QHP9.051), Effective 01/01/2022
|
Qualified Health Plan |
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Prescription Compounds (Policy QHP9.054), Effective 01/01/2022
|
Qualified Health Plan |
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Cystic Fibrosis Agents (Policy QHP9.100), Effective 01/01/2022
|
Qualified Health Plan |
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Hereditary Angioedema (Policy QHP9.101), Effective 01/01/2022
|
Qualified Health Plan |
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Rinvoq (Policy QHP9.102), Effective 05/01/2022
|
Qualified Health Plan |
 |
Topical Immunomodulators (Policy QHP9.103), Effective 01/01/2022
|
Qualified Health Plan |
 |
Sublingual Immunotherapy (SLIT) Medications (Policy QHP9.104), Effective 01/01/2022
|
Qualified Health Plan |
 |
Esbriet (Policy QHP9.105), Effective 01/01/2022
|
Qualified Health Plan |
 |
Promacta (Policy QHP9.107), Effective 01/01/2022
|
Qualified Health Plan |
 |
Asthma-Allergy Monoclonal Antibodies (Policy QHP9.109), Effective 01/01/2022
|
Qualified Health Plan |
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Immune Globulin (Policy QHP9.110), Effective 01/01/2022
|
Qualified Health Plan |
 |
Acthar H.P. Gel (Policy QHP9.112), Effective 01/01/2022
|
Qualified Health Plan |
 |
Acterma (Tocilizumab) (Policy QHP9.113), Effective 03/01/2022
|
Qualified Health Plan |
 |
Arcalyst (Rilonacept) (Policy QHP9.114), Effective 01/01/2022
|
Qualified Health Plan |
 |
Benlysta (Belimumab) (Policy QHP9.115), Effective 01/01/2022
|
Qualified Health Plan |
 |
Cimzia (Certolizumab pegol) (Policy QHP9.116), Effective 04/01/2022
|
Qualified Health Plan |
 |
Cosentyx (Secukinumab) (Policy QHP9.117), Effective 04/01/2022
|
Qualified Health Plan |
 |
Dupixent (Dupilumab) (Policy QHP9.118), Effective 01/01/2022
|
Qualified Health Plan |
 |
Enbrel (Etanercept) (Policy QHP9.119), Effective 11/01/2021
|
Qualified Health Plan |
 |
Entyvio (Policy QHP9.120), Effective 01/01/2022
|
Qualified Health Plan |
 |
Humira (Policy QHP9.121), Effective 01/01/2022
|
Qualified Health Plan |
 |
Infliximab Products (Policy QHP9.123), Effective 01/01/2022
|
Qualified Health Plan |
 |
Methotrexate (Policy QHP9.125), Effective 01/01/2022
|
Qualified Health Plan |
 |
Orencia SC (Policy QHP9.126), Effective 04/01/2022
|
Qualified Health Plan |
 |
Otezla (Policy QHP9.127), Effective 01/01/2022
|
Qualified Health Plan |
 |
Simponi (Policy QHP9.128), Effective 04/01/2022
|
Qualified Health Plan |
 |
Stelara (Policy QHP9.129), Effective 01/01/2022
|
Qualified Health Plan |
 |
Taltz (Policy QHP9.130), Effective 01/01/2022
|
Qualified Health Plan |
 |
Xeljanz (Policy QHP9.131), Effective 04/05/2022
|
Qualified Health Plan |
 |
Ofev (Policy QHP9.133), Effective 01/01/2022
|
Qualified Health Plan |
 |
Complement Inhibitors (Policy QHP9.134), Effective 03/01/2022
|
Qualified Health Plan |
 |
Tavalisse (Policy QHP9.136), Effective 01/01/2022
|
Qualified Health Plan |
 |
Step Therapy - Gout Agents (Policy QHP9.137), Effective 01/01/2022
|
Qualified Health Plan |
 |
Step Therapy- Pulmonary Agents (Policy QHP9.138), Effective 01/01/2022
|
Qualified Health Plan |
 |
Skyrizi (risankizumab-rzaa) (Policy QHP9.140), Effective 04/01/2022
|
Qualified Health Plan |
 |
Actimmune (Policy QHP9.146), Effective 01/01/2022
|
Qualified Health Plan |
 |
Ilumya (Policy QHP9.149), Effective 03/01/2022
|
Qualified Health Plan |
 |
Tremfya (Policy QHP9.150), Effective 01/01/2022
|
Qualified Health Plan |
 |
Kevzara (Policy QHP9.151), Effective 03/01/2022
|
Qualified Health Plan |
 |
Siliq (Policy QHP9.152), Effective 03/01/2022
|
Qualified Health Plan |
 |
Lupkynis (Policy QHP9.153), Effective 01/01/2022
|
Qualified Health Plan |
 |
Actemra-IV (Policy QHP9.156), Effective 01/01/2022
|
Qualified Health Plan |
 |
Orencia IV (Policy QHP9.158), Effective 04/01/2022
|
Qualified Health Plan |
 |
Nuedexta (Policy QHP9.200), Effective 06/01/2021
|
Qualified Health Plan |
 |
Diacomit (Policy QHP9.201), Effective 06/01/2021
|
Qualified Health Plan |
 |
Savella (Policy QHP9.202), Effective 06/01/2021
|
Qualified Health Plan |
 |
VMAT 2 Inhibitors (Policy QHP9.204), Effective 06/01/2021
|
Qualified Health Plan |
 |
Calcitonin-Gene Related Peptide Antagonist (CGRP) (Policy QHP9.205), Effective 06/01/2021
|
Qualified Health Plan |
 |
Pregabalin (Policy QHP9.206), Effective 06/01/2021
|
Qualified Health Plan |
 |
Narcolepsy (Policy QHP9.208), Effective 06/01/2021
|
Qualified Health Plan |
 |
Botox (Policy QHP9.209), Effective 06/01/2021
|
Qualified Health Plan |
 |
Opioids (Policy QHP9.210), Effective 06/01/2021
|
Qualified Health Plan |
 |
Insomnia Agents (Policy QHP9.211), Effective 06/01/2021
|
Qualified Health Plan |
 |
Multiple Sclerosis (Policy QHP9.212), Effective 11/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Anticonvulsants (Policy QHP9.214), Effective 06/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Migraine Agents (Policy QHP9.215), Effective 06/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Sleep Disorder Agents (Policy QHP9.216), Effective 06/01/2021
|
Qualified Health Plan |
 |
Epidolex (Policy QHP9.222), Effective 06/01/2021
|
Qualified Health Plan |
 |
Vigabatrin (Policy QHP9.223), Effective 06/01/2021
|
Qualified Health Plan |
 |
Fintepla (Policy QHP9.224), Effective 06/01/2021
|
Qualified Health Plan |
 |
Dojolvi (Policy QHP9.231), Effective 09/01/2021
|
Qualified Health Plan |
 |
Isturisa (Policy QHP9.233), Effective 09/01/2021
|
Qualified Health Plan |
 |
Zeposia (Policy QHP9.234), Effective 3/01/2022
|
Qualified Health Plan |
 |
Egrifta (Policy QHP9.304), Effective 01/01/2021
|
Qualified Health Plan |
 |
Egrifta (Policy QHP9.304), Effective 09/01/2021
|
Qualified Health Plan |
 |
Signifor (Policy QHP9.306), Effective 01/01/2021
|
Qualified Health Plan |
 |
Signifor (Policy QHP9.306), Effective 09/01/2021
|
Qualified Health Plan |
 |
Myalept (Policy QHP9.307), Effective 01/01/2021
|
Qualified Health Plan |
 |
Myalept (Policy QHP9.307), Effective 09/01/2021
|
Qualified Health Plan |
 |
Rayaldee (Policy QHP9.314), Effective 01/01/2021
|
Qualified Health Plan |
 |
Rayaldee (Policy QHP9.314), Effective 09/01/2021
|
Qualified Health Plan |
 |
Increlex (Policy QHP9.317), Effective 01/01/2021
|
Qualified Health Plan |
 |
Increlex (Policy QHP9.317), Effective 09/01/2021
|
Qualified Health Plan |
 |
Metabolic Bone Disease Agents (Policy QHP9.318), Effective 01/01/2021
|
Qualified Health Plan |
 |
Metabolic Bone Disease Agents (Policy QHP9.318), Effective 09/01/2021
|
Qualified Health Plan |
 |
Samsca (Policy QHP9.319), Effective 01/01/2021
|
Qualified Health Plan |
 |
Samsca/Tolvaptan (Policy QHP9.319), Effective 09/01/2021
|
Qualified Health Plan |
 |
Non-Preferred Blood Glucose Testing Products (Policy QHP9.320), Effective 09/01/2021
|
Qualified Health Plan |
 |
Givlaari (Policy QHP9.321), Effective 01/01/2021
|
Qualified Health Plan |
 |
Givlaari (Policy QHP9.321), Effective 09/01/2021
|
Qualified Health Plan |
 |
Anti-Obesity Medications (Policy QHP9.322), Effective 07/01/2021
|
Qualified Health Plan |
 |
Anti-Obesity Medications (Policy QHP9.322), Effective 01/01/2022
|
Qualified Health Plan |
 |
Genotropin (Policy QHP9.325), Effective 01/01/2021
|
Qualified Health Plan |
 |
Genotropin (Policy QHP9.325), Effective 09/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Antidiabetic Agents (Policy QHP9.327), Effective 01/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Antidiabetic Agents (Policy QHP9.327), Effective 01/01/2022
|
Qualified Health Plan |
 |
Somavert (Pegvisomant) (Policy QHP9.328), Effective 01/01/2021
|
Qualified Health Plan |
 |
Somavert (pegvisomant) (Policy QHP9.328), Effective 09/01/2021
|
Qualified Health Plan |
 |
QHP9.340_Zokinvy_Rev2021_NEW
|
Qualified Health Plan |
 |
Zokinvy (Policy QHP9.340), Effective 09/01/2021
|
Qualified Health Plan |
 |
Systemic Antibiotics (Policy QHP9.403), Effective 06/01/2021
|
Qualified Health Plan |
 |
Hepatitis C (Policy QHP9.404), Effective 06/01/2021
|
Qualified Health Plan |
 |
Synagis (Policy QHP9.405), Effective 06/01/2021
|
Qualified Health Plan |
 |
Antifungal Agents (Policy QHP9.406), Effective 06/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Pediculicide Agents (Policy QHP9.408), Effective 06/01/2021
|
Qualified Health Plan |
 |
Chloroquine and Hydroxychloroquine (Policy QHP9.410), Effective 06/01/2021
|
Qualified Health Plan |
 |
Descovy (Policy QHP9.411), Effective 06/01/2021
|
Qualified Health Plan |
 |
Antimycobaterial Agents (Policy QHP9.412), Effective 06/01/2021
|
Qualified Health Plan |
 |
Antidepressants (Policy QHP9.502), Effective 09/01/2021
|
Qualified Health Plan |
 |
Antipsychotics (Policy QHP9.503), Effective 06/01/2021
|
Qualified Health Plan |
 |
Buprenorphine and Naloxone Products (Policy QHP9.504), Effective 07/01/2021
|
Qualified Health Plan |
 |
ADHD Medications (Policy QHP9.505), Effective 06/01/2021
|
Qualified Health Plan |
 |
Step Therapy - Anti-Depressant / Anti-Psychotic Agents (Policy QHP9.506), Effective 06/01/2021
|
Qualified Health Plan |
 |
Pulmonary Hypertension (Policy QHP9.600), Effective 03/01/2022
|
Qualified Health Plan |
 |
ACEIs and ARBSs (Policy QHP9.601), Effective 03/01/2022
|
Qualified Health Plan |
 |
Homozygous Familial Hypercholesterolemia (Policy QHP9.603), Effective 03/01/2022
|
Qualified Health Plan |
 |
Droxidopa (Policy QHP9.604), Effective 03/01/2022
|
Qualified Health Plan |
 |
PCSK9 Inhibitors (Policy QHP9.605), Effective 03/01/2022
|
Qualified Health Plan |
 |
Entresto (Policy QHP9.606), Effective 01/01/2021
|
Qualified Health Plan |
 |
Erythropoiesis Stimulating Agents (Policy QHP9.609), Effective 03/01/2022
|
Qualified Health Plan |
 |
Adakveo (Policy QHP9.611), Effective 03/01/2022
|
Qualified Health Plan |
 |
Oxbryta (Policy QHP9.612), Effective 03/01/2022
|
Qualified Health Plan |
 |
Reblozyl (Policy QHP9.613), Effective 03/01/2022
|
Qualified Health Plan |
 |
Step Therapy - Antihypertensive Agents (Policy QHP9.615), Effective 03/01/2022
|
Qualified Health Plan |
 |
Step Therapy- Dyslipidemia Agents (Policy QHP9.616), Effective 03/01/2022
|
Qualified Health Plan |
 |
Corlanor (Policy QHP9.620), Effective 03/01/2022
|
Qualified Health Plan |
 |
Pegfilgrastim Agents (Policy QHP9.622), Effective 03/01/2022
|
Qualified Health Plan |
 |
Iron Chelating Agents (Policy QHP9.625), Effective 03/01/2022
|
Qualified Health Plan |
 |
Kuvan (Policy QHP9.626), Effective 01/01/2021
|
Qualified Health Plan |
 |
Sapropterin (Policy QHP9.626), Effective 09/01/2021
|
Qualified Health Plan |
 |
Mulpleta (Policy QHP9.627), Effective 03/01/2022
|
Qualified Health Plan |
 |
Pradaxa (Policy QHP9.628), Effective 01/01/2021
|
Qualified Health Plan |
 |
Colony Stimulating Agents Filgrastim Agents (Policy QHP9.629), Effective 03/01/2022
|
Qualified Health Plan |
 |
Verquvo (Policy QHP9.630), Effective 03/01/2022
|
Qualified Health Plan |
 |
Antineoplastic Agents (Policy QHP9.700), Effective 01/01/2021
|
Qualified Health Plan |
 |
Antineoplastic Agents (Policy QHP9.700), Effective 09/01/2021
|
Qualified Health Plan |
 |
GnRH Agents (Policy QHP9.703), Effective 03/01/2022
|
Qualified Health Plan |
 |
Rituximab (Policy QHP9.704), Effective 01/01/2021
|
Qualified Health Plan |
 |
Rituximab (Policy QHP9.704), Effective 09/01/2021
|
Qualified Health Plan |
 |
Tepezza (Policy QHP9.705), Effective 01/01/2021
|
Qualified Health Plan |
 |
Tepezza (Policy QHP9.705), Effective 09/01/2021
|
Qualified Health Plan |
 |
Enhertu (Policy QHP9.706), Effective 01/01/2021
|
Qualified Health Plan |
 |
Enhertu (Policy QHP9.706), Effective 09/01/2021
|
Qualified Health Plan |
 |
Padcev (Policy QHP9.707), Effective 01/01/2021
|
Qualified Health Plan |
 |
Padcev (Policy QHP9.707), Effective 09/01/2021
|
Qualified Health Plan |
 |
Gavreto (Policy QHP9.719), Effective 09/01/2021
|
Qualified Health Plan |
 |
Inqovi (Policy QHP9.720), Effective 09/01/2021
|
Qualified Health Plan |
 |
Monjuvi (Policy QHP9.721), Effective 09/01/2021
|
Qualified Health Plan |
 |
Onureg (Policy QHP9.722), Effective 09/01/2021
|
Qualified Health Plan |
 |
Pepaxto/Blenrep (Policy QHP9.723), Effective 09/01/2021
|
Qualified Health Plan |
 |
Tabrecta (Policy QHP9.724), Effective 09/01/2021
|
Qualified Health Plan |
 |
Uplinza (Policy QHP9.725), Effective 09/01/2021
|
Qualified Health Plan |
 |
Xpovio (Policy QHP9.726), Effective 09/01/2021
|
Qualified Health Plan |
 |
Ayvakit (Policy QHP9.727), Effective 09/01/2021
|
Qualified Health Plan |
 |
Ibrance (Policy QHP9.728), Effective 09/01/2021
|
Qualified Health Plan |
 |
Imbruvica (Policy QHP9.729), Effective 09/01/2021
|
Qualified Health Plan |
 |
Jakafi (Policy QHP9.730), Effective 09/01/2021
|
Qualified Health Plan |
 |
Jelmyto (Policy QHP9.731), Effective 09/01/2021
|
Qualified Health Plan |
 |
Pemazyre (Policy QHP9.732), Effective 09/01/2021
|
Qualified Health Plan |
 |
Qinlock (Policy QHP9.733), Effective 09/01/2021
|
Qualified Health Plan |
 |
Tagrisso (Policy QHP9.734), Effective 09/01/2021
|
Qualified Health Plan |
 |
Trodelvy (Policy QHP9.735), Effective 09/01/2021
|
Qualified Health Plan |
 |
Tukysa (Policy QHP9.736), Effective 09/01/2021
|
Qualified Health Plan |
 |
Zepzelca (Policy QHP9.737), Effective 09/01/2021
|
Qualified Health Plan |
 |
Benign Prostatic Hyperplasia (BPH) Medications (Policy QHP9.805), Effective 03/01/2022
|
Qualified Health Plan |
 |
Step Therapy - Proton Pump Inhibitors (Policy QHP9.806), Effective 03/01/2022
|
Qualified Health Plan |
 |
Infertility Medications (Policy QHP9.808), Effective 03/01/2022
|
Qualified Health Plan |
 |
Oriahnn & Myfembree (Policy QHP9.812), Effective 03/01/2022
|
Qualified Health Plan |
 |
Bylvay (Policy QHP9.814), Effective 03/01/2022
|
Qualified Health Plan |
 |
Xiidra (Policy QHP9.902), Effective 03/01/2022
|
Qualified Health Plan |
 |
Mytesi (Policy QHP9.903), Effective 03/01/2022
|
Qualified Health Plan |
 |
Antiemetics (Policy QHP9.905), Effective 03/01/2022
|
Qualified Health Plan |
 |
Topical Corticosteroids (Policy QHP9.906), Effective 03/01/2022
|
Qualified Health Plan |
 |
Anabolic Steroids (Policy QHP9.907), Effective 03/01/2022
|
Qualified Health Plan |
 |
Acne and Rosacea Agents (Policy QHP9.908), Effective 03/01/2022
|
Qualified Health Plan |
 |
Viscosupplements (Policy QHP9.909), Effective 03/01/2022
|
Qualified Health Plan |
 |
Rhopressa (Policy QHP9.912), Effective 03/01/2022
|
Qualified Health Plan |
 |
Step Therapy - Glaucoma (Policy QHP9.913), Effective 03/01/2022
|
Qualified Health Plan |
 |
Anti-Allergy Ophthalmic Agents (Policy QHP9.914), Effective 03/01/2022
|
Qualified Health Plan |