Pharmacy Services

Pharmacy Services

Mass Advantage Comprehensive Formulary

Find all the information you need about your prescriptions in one place. Access or download the formulary by following the link below.

Pharmacy Authorizations

Some drugs require prior authorization. If you need help understanding your options or what those drugs are, we can help!

For information on authorizations call:

HMO: 1-844-918-0114
PPO: 1-844-915-0234

From October 1 to March 31, we are available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are available Monday through Friday from 8 a.m.to 8 p.m.EST.

Find A Pharmacy

Follow the link below to find a pharmacy within the MassAdvantage Health Plan network near you.

EXCEPTIONS & COVERAGE DETERMINATIONS

If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements or a decrease to your cost-sharing amount, you can request an exception.

  • What is an exception? An exception is a type of initial determination (also called a "coverage determination") involving a Part D drug. You, your doctor or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations including:
  • Asking us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
  • Asking us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
    • Asking us to pay a lower price for a covered Part D drug on a higher cost sharing tier through the tiering exception process.
    • If our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost sharing amount that applies to the alternative drug(s). This could lower your share of the cost for the drug.
    • If we approve your request for a tiering exception and there is more than one lower cost-sharing tier with alternative drugs you can’t take, you will usually pay the lowest amount.
    • You cannot ask us to change the cost sharing tier of any drug in the Specialty tier (Tier 5).

For information on Authorizations, call:
HMO:1-844-918-0114
PPO:1-844-915-0234
Calls to this number are free.

From October 1 to March 31, we’re available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we’re available Monday through Friday from 8 a.m. to 8 p.m. EST.

You may be eligible for more help for your Part D Plan through Low Income Subsidy (LIS) aid. Click here for more LIS information.

DOWNLOAD COVERAGE DETERMINATION FORM
Fill Out Coverage Determination Form

TRANSITION

As a new or continuing member to Mass Advantage, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a coverage determination so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply if you are not a resident of a long-term care facility. If you are a member of a long-term care facility, we will cover a temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum day supply of medication. After your first 30-day supply outside of a long-term care facility or 31-day supply within a long-term care facility, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a coverage determination. For enrollees admitted or discharged from a long-term care facility or have had any change in level of care, early refill edits will not be used to limit appropriate and necessary access to your Part D benefit, and you are allowed to access a refill upon admission or discharge without restrictions.

If you are a new or current Medicare Part D enrollee transitioning from one treatment setting to another or experience transitions due to level of care changes, Mass Advantage will provide a supply of medication in compliance with transition requirements and continuity of care provisions.

  • At a retail pharmacy a one-time 30-day transition supply (unless the prescription is written for less than 30 days) will be authorized with refills to total 30 days of medication if needed.
  • If you are a resident of a long-term care facility, a 31-day supply (unless the prescription is written for less) will be authorized with refills to total 31 days of medication if needed.

After authorizing the temporary refills referred to above, we will send you and your doctor a letter detailing the temporary nature of the transition supply you have received, instructions for working with the plan and your doctor to identify appropriate therapeutic alternatives that are in the Mass Advantage Medicare Part D formularies, an explanation of your right to request a formulary exception and a description of the procedures for requesting a coverage determination.

 

MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM

We have a program that can help our members with complex health needs.

This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. This program can help make sure that our members get the most benefit from the drugs they take. Our program is called a Medication Therapy Management (MTM) program.

Some members who take medications for different medical conditions and have high drug costs or are in a DMP to help members use their opioids safely may be able to get services through an MTM program. A pharmacist or other health professional will give you a comprehensive review of all your medications. You can talk about how best to take your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You’ll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You’ll also get a personal medication list that will include all the medications you’re taking and why you take them. In addition, members in the MTM program will receive information on the safe disposal of prescription medications that are controlled substances.

It’s a good idea to have your medication review before your yearly “Wellness” visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, keep your medication list with you (for example, with your ID) in case you go to the hospital or emergency room.

If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Member Services.