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2021MassHealth Pharmacy FormularyINTRODUCTIONAllWays Health Partners covers a wide variety of safe and effective medications for treating ourmembers' medical needs. This list of AllWays Health Partners’ covered medications shows the tier inwhich medications are placed. You can use this list to find out if your drug is covered and at which tier.Check the plan documents such as the schedule of benefits, the summary of benefits and coverage, or thebenefit handbook for details on coverage and cost sharing. If you are a member, you also can view yourprescription drug coverage information by logging in to allwaysmember.org. This list of coveredmedications is continually updated based on recommendations by AllWays Health Partners’ Pharmacy& Therapeutics Committee.It is always a good idea to discuss your medication options with your doctor to decide which is the mostappropriate to treat your specific medical condition.LEGEND 0ALM90PAQLSPSTPDBPMBDualCAPITALIZED lowercaseZero Dollar CopayAge LimitMaintenance 90 drugPrior AuthorizationQuantity LimitSpecialty DrugStep TherapyPreferred DrugBrand Name PreferredAvailable on the medical benefit onlyAvailable on medical and pharmacy benefitIndicates a brand name drugIndicates a generic drugNOTICEThe information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2019 All rights reserved. This document containsreferences to brand-name prescription drugs that are trademarks or registered trademarks ofpharmaceutical manufacturers.When viewing the document via the Internet, please be advised that the document is updatedperiodically, and changes may appear prior to their effective date to allow for client notification.This list is subject to change at any time.AllWays Health Partners complies with applicable federal civil rights laws and does not discriminateor exclude people on the basis of race, color, national origin, age, disability, or sex.399 Revolution Drive, Suite 810, Somerville, MA 02145 allwayshealthpartners.orgAllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company
Covered ProductReference1st Tier Unifine Pentips 29G X 12MM ,31G X 6 MMCareFine Pen Needles 0M901st Tier Unifine Pentips 31G X 5 MM ,31G X 8 MMAdvocate Insulin PenNeedles 0M901st Tier Unifine Pentips 32G X 4 MMBD Pen Needle Nano U/F 0M901st Tier Unifine Pentips Plus 29G X12MM , 31G X 6 MMCareFine Pen Needles 0M901st Tier Unifine Pentips Plus 31G X 5MM , 31G X 8 MMAdvocate Insulin PenNeedles 0M901st Tier Unifine Pentips Plus 32G X 4MMBD Pen Needle Nano U/F 0M903 Day VaginalGyne-Lotrimin 3Tier 2M9050 Adult Eye HealthDEKAs PlusTier 2M907 Series BP Monitor/Upper ArmTier Status Notes 0M90; QL (QL Flag);QL (1 EA per 3YEARs)8 Hour Pain ReliefMidolTier 2M908 Hour Pain RelieverMidolTier 2M90Tier 2M90A D Personal Care LotionA Thru Z AdvancedABC Plus SeniorTier 2M90A Thru Z High PotencyABC Plus SeniorTier 2M90A Thru Z Select 50 AdvancedABC Plus SeniorTier 2M90A Thru Z Select 50 MensABC Plus SeniorTier 2M90A Thru Z Select AdvancedABC Plus SeniorTier 2M90A Thru Z Select Oral TabletABC Plus SeniorTier 2M90A Thru Z Select Ultimate WomenABC Plus SeniorTier 2M90A Thru Z Ultimate MensABC Plus SeniorTier 2M90Abacavir Sulfate Oral SolutionZiagenTier 2Abacavir Sulfate Oral TabletZiagenTier 2M90Abacavir Sulfate-lamiVUDineEpzicomTier 2M90Abacavir-Lamivudine-ZidovudineTrizivirTier 2M90Tier 2M90Tier 2M90Abilify Maintena Intramuscular PrefilledSyringeTier 2PA; QL (QuantityLimit Applies); QL (1INJ per 30 days)Abilify Maintena IntramuscularSuspension Reconstituted ERTier 2PA; QL (QuantityLimit Applies); QL (1INJ per 30 days)Abilify MyCite Oral Tablet 10 MG, 2MG, 5 MGTier 2PA; QL (60 EA per 30days)Abatron AFABC PlusABC Plus Senior1
Covered ProductReferenceAbilify MyCite Oral Tablet 15 MG, 20MG, 30 MGTier Status NotesTier 2PA; QL (30 EA per 90days)Abiraterone Acetate Oral Tablet 250 MG Zytiga 0SP; QL (QL Applies)Abiraterone Acetate Oral Tablet 500 MG Zytiga 0QL (60 EA per 30days)Abraxane 0M90Tier 2M90Tier 1M90Acebutolol HCl OralTier 1M90Acephen Rectal Suppository 120 MG, 325MGTier 2M90Acamprosate CalciumAcarbose OralPrecoseAcetaminophen ERMidolTier 2M90Acetaminophen Extra Strength OralLiquidMapap AcetaminophenExtra StrTier 2M90Acetaminophen Extra Strength OralTabletHealthy Mama ShakeThat AcheTier 2M90Acetaminophen Oral LiquidLittle Remedies for FeverTier 2M90Tier 2M90Tier 2M90Acetaminophen Oral Tablet Chewable 80Childrens Medi-TabsMGTier 2M90Acetaminophen Rectal Suppository 120MGTier 2M90Acetaminophen-Codeine #2Tier 2QL (400 tablets per 30days. Click;HERE)Acetaminophen-Codeine #3Tier 2QL (360 tablets per 30days. Click;HERE)Acetaminophen-Codeine #4Tier 2QL (180 EA per 30days)Acetaminophen-Codeine Oral SolutionTier 2M90; QL (2700 mLper 30 days.Click;HERE)Acetaminophen-Codeine Oral Tablet 30015 MGTier 2M90; QL (400 tabletsper 30 days.Click;HERE)Acetaminophen-Codeine Oral Tablet 30030 MGTier 2M90Acetaminophen-Codeine Oral Tablet 30060 MGTier 2M90; QL (180 EA per30 days)Acetasol HCTier 2M90acetaZOLAMIDE ERTier 1M90Acetaminophen Oral Solution 160MG/5MLAcetaminophen Oral Tablet2AphenFeverAll Childrens
Covered ProductReferenceTier Status NotesacetaZOLAMIDE OralTier 1M90Acetic Acid OticTier 2M90Acetic Acid-Aluminum AcetateTier 2M90Acetylcysteine InhalationTier 2M90Acid ControlTier 2M90Acid Control Maximum Strength OralTablet 20 MGMM Acid-Pep MaximumStrengthTier 2M90Acid ControllerPepcid ACTier 2M90Acid Controller Max StMM Acid-Pep MaximumStrengthTier 2M90Acid Reducer Maximum StrengthMM Acid-Pep MaximumStrengthTier 2M90Acid Reducer Oral Tablet 10 MGPepcid ACTier 2M90Acid Reducer Oral Tablet 150 MG, 75MGTier 2M90AcipHex Sprinkle Oral Capsule Sprinkle 5MGTier 2M90; QL (30 EA per90 days)AcitretinTier 2M90Acne Foaming WashMedpura BenzoylPeroxideTier 2M90Acne Medication 10 External GelClean & Clear Persa-GelMax StTier 2M90Acne Medication 5 External GelMedpura BenzoylPeroxideTier 2M90Acne-ClearClean & Clear Persa-GelMax StTier 2M90Actemra ACTPenTier 2PA; SP; Dual; QL (4PENS per 28 days)Actemra Intravenous Solution 200MG/10MLTier 2PA; SP; Dual; QL (4VIALS per 14 days)Actemra Intravenous Solution 400MG/20MLTier 2PA; SP; Dual; QL (2VIALS per 14 days)Actemra Intravenous Solution 80MG/4MLTier 2PA; SP; Dual; QL (10VIALS per 28 days)Actemra SubcutaneousTier 2PA; SP; Dual; QL (4SYR per 28 days)ActharTier 2PA; SP; QL (35 ml per21 days)ActHIB 0M90Tier 2M90ActicalDEKAs PlusActimmune 0Activite ECTier 2SPM903
Covered ProductReferenceTier Status NotesActoplus met XRTier 2ST; M90AcuvailTier 2ST; M90; QL (60mlper 25 days)Acyclovir External OintmentZoviraxTier 2M90Acyclovir OralZoviraxTier 2M90Tier 2M90Adacel Intramuscular Suspension 5-2-15.5LF-MCG/0.5 0M90AdagenMBPAAdakveoMBPAAcyclovir Sodium Intravenous SolutionAdapalene External CreamDifferinTier 2ST; M90Adapalene External Gel 0.3 %DifferinTier 2ST; M90Adapalene External LotionDifferinTier 2ST; M90Adcetris 0AddaprinTier 2M90Adderall XRTier 2PD; BP; QL (60 EAper 30 days)Tier 2SP; QL (30 EA per 90days)AdempasTier 2PA; SPAdenosine Intravenous Solution 12MG/4ML, 6 MG/2MLTier 2M90AdmelogTier 1PAAdmelog SoloStarTier 1PAAdrenalin NasalTier 2Adefovir DipivoxilHepseraAdrucil 0SPM90Advair DiskusTier 2BPAdvair HFATier 2M90Tier 2M90AdvateTier 2PA; SP; DualAdvil Junior StrengthTier 2M90 0M90Advanced Diabetic MultivitaminAdvocate Insulin Pen Needles 29G X12.7MM , 31G X 5 MM , 31G X 8 MMABC Plus SeniorAdynovateTier 2PA; SP; DualAdzenys XR-ODT Oral Tablet ExtendedRelease Dispersible 12.5 MG, 15.7 MG,18.8 MG, 6.3 MG, 9.4 MGTier 2QL (30 EA per 90days)Adzenys XR-ODT Oral Tablet ExtendedRelease Dispersible 3.1 MGTier 2PA; QL (30 EA per 90days)AerospanTier 2M904
Covered ProductReferenceAfeditab CRTier Status NotesTier 1M90Afinitor Oral Tablet 10 MG 0PA; SP; BP; QL (30EA per 30 days)Afinitor Oral Tablet 2.5 MG, 5 MG, 7.5MG 0PA; BP; QL (30 EAper 30 days)Afluria 0M90Afluria Preservative Free IntramuscularSuspension Prefilled Syringe 0M90Afluria Quadrivalent IntramuscularSuspension 0Afluria Quadrivalent IntramuscularSuspension Prefilled Syringe 0.25 ML 0Afluria Quadrivalent IntramuscularSuspension Prefilled Syringe 0.5 ML 0M90Afrin Saline Nasal MistTier 1M90AfstylaTier 2PA; SP; DualAftera 0M90AimovigTier 2PA; QL (1 PEN per 30days)AirDuo RespiClick 113/14Tier 2PAAirDuo RespiClick 232/14Tier 2PAAirDuo RespiClick 55/14Tier 2PAAjovyTier 2PA; PD; QL (3 PENSper 90 days)AktenTier 2M90AL12Tier 2M90Tier 2M90Ala-QuinTier 2M90Alavert Oral TabletTier 2M90; QL (QL Flag)Alavert Oral Tablet DispersibleTier 2M90AlawayTier 2M90; QL (QL Flag)Alaway Childrens AllergyTier 2M90; QL (QL Flag)Ala-Cort External Cream 1 %Albendazole OralAveeno Anti-Itch Max StAlbenzaTier 2Albuterol Sulfate ERTier 2M90Albuterol Sulfate Inhalation NebulizationSolution (2.5 MG/3ML) 0.083%, (5MG/ML) 0.5%, 0.63 MG/3ML, 1.25MG/3MLTier 2M90Albuterol Sulfate OralTier 2M90Alclometasone Dipropionate ExternalCreamTier 2ST; M90; QL (QLApplies)5
Covered ProductReferenceTier Status NotesAlclometasone Dipropionate ExternalOintmentTier 2M90Aldactazide Oral Tablet 50-50 MGTier 2M90AldurazymeTier 2PA; SP; DualAlecensa 0SP; QL (240 EA per 30days)Alendronate Sodium Oral SolutionTier 2M90Alendronate Sodium Oral Tablet 10 MG,40 MG, 5 MGTier 2M90; QL (30 EA per90 days)Alendronate Sodium Oral Tablet 35 MGTier 2M90; QL (4 tablets per28 days; 13 tablets per90 days)Alendronate Sodium Oral Tablet 70 MGFosamaxTier 2M90; QL (4 tablets per28 days; 13 tablets per90 days)Aler-CapBanophenTier 2M90AlerTabAlka-Seltzer Plus AllergyTier 2M90Alferon NAlfuzosin HCl ER 0UroxatralAlimtaTier 2MBAlinia Oral Suspension ReconstitutedTier 2Aliqopa 0SPM90; QL (30 EA per90 days)PAM90PAAlka-Seltzer Plus AllergyTier 2M90Alkeran OralTier 1M90All Day Allergy Childrens Oral SolutionKLS Aller-Tec ChildrensTier 2M90; QL (QL Flag)All Day Allergy Childrens Oral TabletChewable 10 MGWal-Zyr ChildrensTier 2M90; QL (QL Flag)All Day Allergy Oral TabletKLS Aller-TecTier 2M90; QL (QL Flag)All Day Pain ReliefMediproxenTier 2M90All Day ReliefMediproxenTier 2M90Tier 2M90; QL (QL Flag)Allegra Allergy Childrens Oral TabletDispersibleAller-ChlorDiabetic Tussin AllergyTier 2M90Aller-Ease Oral Tablet 60 MGWal-Fex AllergyTier 2M90; QL (60 EA per30 days)Allergy 24-HRKLS Aller-FexTier 2M90; QL (QL Flag)Allergy 4 HourWal-finateTier 2M90Allergy Childrens Oral LiquidBanophenTier 2M90Allergy EyeNaphcon-ATier 2M90Allergy Eye DropsAlawayTier 2M90; QL (QL Flag)6
Covered ProductReferenceTier Status NotesAllergy MedicationAlka-Seltzer Plus AllergyTier 2M90Allergy Medication ChildrensBanophenTier 2M90Allergy Oral CapsuleBanophenTier 2M90Allergy Oral Tablet 10 MGKLS AllerClearTier 2M90; QL (QL Flag)Allergy Oral Tablet 25 MGAlka-Seltzer Plus AllergyTier 2M90Allergy Oral Tablet 4 MGWal-finateTier 2M90Allergy Oral Tablet DispersibleAlavertTier 2M90Allergy Oral Tablet Extended ReleaseChlor-Trimeton AllergyTier 2M90Allergy Relief ChildClaritin Allergy ChildrensTier 2M90; QL (300ml permonth)Allergy Relief Childrens Oral LiquidBanophenTier 2M90Allergy Relief Childrens Oral Solution 5MG/5MLClaritin Allergy ChildrensTier 2M90; QL (QL Flag)Allergy Relief Childrens Oral SyrupClaritin Allergy ChildrensTier 2M90; QL (300ml permonth)Allergy Relief Childrens Oral TabletChewableWal-Zyr ChildrensTier 2M90; QL (QL Flag)Allergy Relief Childrens Oral TabletDispersible 10 MGAlavertTier 2M90Allergy Relief NighttimeAlka-Seltzer Plus AllergyTier 2M90Allergy Spray 24 Hour Nasal Suspension ClariSprayTier 2M90Allergy-TimeWal-finateTier 2M90Allopurinol OralZyloprimTier 2M90Almotriptan MalateTier 2M90; QL (12 tabletsper month)AlocrilTier 2M90Aloe Aftersun External LotionTier 2M90Alogliptin BenzoateNesinaTier 1PA; M90; QL (30 EAper 90 days)Alogliptin-Metformin HClKazanoTier 2ST; M90; QL (60 EAper 30 days)Alogliptin-PioglitazoneOseniTier 1PA; M90; QL (30 EAper 90 days)AlomideTier 2M90AlophenTier 2M90AloraTier 2M90Tier 2M90Alphagan P Ophthalmic Solution 0.1 %Tier 2M90Alphanate/VWF Complex/HumanTier 2PA; SP; DualAlphaNine SDTier 2PA; SP; DualAlosetron HClLotronex7
Covered ProductReferenceALPRAZolam IntensolALPRAZolam Oral TabletTier Status NotesTier 2XanaxTier 2AlprolixTier 2PA; SP; DualAlrexTier 2M90AltabaxTier 2PA; M90AltacaineTier 2M90AltafluorTier 2M90Altafrin Ophthalmic Solution 10 %, 2.5 %Tier 2M90Tier 1M90Tier 2M90Altavera 0M90Alunbrig Oral Tablet 180 MG, 90 MG 0SP; QL (30 EA per 30days)Alunbrig Oral Tablet 30 MG 0SP; QL (120 EA per 30days)Alunbrig Oral Tablet Therapy Pack 0SP; QL (30 EA per 30days)Altamist SprayAfrin Saline Nasal MistAltarylAlvescoTier 2PA; M90Alyacen 1/35Cyclafem 1/35 0M90Alyacen 7/7/7Cyclafem 7/7/7 0M90AmabelzTier 2M90Amantadine HCl Oral CapsuleTier 2M90Amantadine HCl Oral SyrupTier 2M90Amantadine HCl Oral TabletTier 2M90Tier 2PA; SP; QL (30 EAper 90 days)AmbrisentanLetairisAmethia 0M90Amethia Lo 0M90Amethyst 0M90Tier 1M90aMILoride HCl OralTier 1M90Amiloride-HydrochlorothiazideTier 1M90Aminoacetic AcidTier 2M90Aminobenzoate Potassium Oral PacketTier 2M90Aminocaproic Acid IntravenousTier 2M90AmifostineEthyolAminocaproic Acid Oral SolutionAmicarTier 2Aminocaproic Acid Oral TabletAmicarTier 2AminofenAphenTier 28M90
Covered ProductReferenceAmiodarone HCl Intravenous Solution150 MG/3ML, 450 MG/9MLTier Status NotesTier 2M90Tier 2M90Amitriptyline HCl OralTier 2M90AmLactin CerapeuticTier 2M90AmLactin External LotionTier 2M90Amiodarone HCl OralPaceroneAmlodipine Besy-Benazepril HClLotrelTier 1M90AmLODIPine Besylate OralNorvascTier 1M90Amlodipine-OlmesartanAzorTier 2PA; ST; M90amLODIPine-Valsartan-HCTZExforge HCTTier 1ST; M90Ammonium Lactate ExternalAL12Tier 2M90Amondys 45MBAmoxapineTier 2M90Amoxicill-Clarithro-LansoprazTier 2M90Amoxicillin Oral CapsuleTier 2M90Amoxicillin Oral SuspensionReconstitutedTier 2M90Amoxicillin Oral TabletTier 2M90Amoxicillin Oral Tablet Chewable 125MG, 250 MGTier 2M90Amoxicillin-Pot Clavulanate ERTier 2M90Tier 2M90AmphadaseTier 2M90Amphetamine ERTier 2PAAmoxicillin-Pot Clavulanate OralAugmentinPAAmphetamine SulfateEvekeoTier 2Amphetamine-DextroamphetamineAdderallTier 2QL (90 EA per 30days)Tier 2M90Tier 2M90 0M90AmpicillinAnagrelide HClAgrylinAnastrozole OralArimidexAndroderm Transdermal Patch 24 HourTier 2AndroGel Transdermal Gel 50 MG/5GM(1%)Tier 2AndroxyTier 2AngeliqTier 2M90Tier 2M90Tier 2M90Tier 2M90Tier 2M90Animal Chews Oral Tablet ChewableBounty Bears/CAnimal ShapesAnimal Shapes Plus IronAnoro ElliptaLand Before TimeMultivitaminST9
Covered ProductReferenceAntacid CalciumCal-Gest AntacidTier 2M90Antacid Calcium Extra StrengthCVS Chewy Not ChalkyFlavorTier 2M90Antacid Extra Strength Oral TabletChewable 750 MGCVS Chewy Not ChalkyFlavorTier 2M90Antacid MaximumTums Ultra 1000Tier 2M90Antacid Oral Tablet Chewable 500 MGCal-Gest AntacidTier 2M90Antacid Ultra Strength Oral TabletChewable 1000 MGTums Ultra 1000Tier 2M90Tier 2M90Antara Oral Capsule 30 MG, 90 MGTier Status NotesAnti-Diarrheal Oral CapsuleImodium A-DTier 2M90Antifungal (Tolnaftate)TinactinTier 2M90Anti-Fungal External Cream 1 %DesenexTier 2M90Anti-Hist AllergyAlka-Seltzer Plus AllergyTier 2M90Anti-Itch Maximum Strength ExternalCream 1 %Aveeno Anti-Itch Max StTier 2M90Antioxidant A/C/E/SeleniumABC Plus SeniorTier 2M90Anti-Oxidant FormulaDEKAs PlusTier 2M90Antioxidant Formula Oral TabletABC Plus SeniorTier 2M90Antioxidant Formula/MineralsDEKAs PlusTier 2M90AntiOxidant ForteABC Plus SeniorTier 2M90Antioxidant Oral CapsuleDEKAs PlusTier 2M90Antioxidant Protection FormulaABC Plus SeniorTier 2M90Antioxidant VitaminsABC Plus SeniorTier 2M90Tier 2M90; QL (1 EA per 30days)Anzemet OralAPAP Extra StrengthHealthy Mama ShakeThat AcheTier 2M90APAP Oral Tablet 325 MGAphenTier 2M90APAP Oral Tablet ChewableChildrens Medi-TabsTier 2M90APAP-Caff-Dihydrocodeine Oral Capsule TrezixTier 2QL (300 Capsules per30 days. Click;HERE)Apatate ForteTier 2M90AphenTier 2M90ApidraTier 1M90Apidra SoloStar Subcutaneous SolutionPen-InjectorTier 1M90Apokyn Subcutaneous Solution CartridgeTier 2SP; QL (20 EA per 30days)Tier 2M90Apra10Medi-Tabs Childrens
Covered ProductReferenceTier Status NotesApraclonidine HClTier 2M90Aprepitant Oral Capsule 125 MGTier 2M90; QL (4 capsulesper 25 days)Aprepitant Oral Capsule 40 MGTier 2M90; QL (1 capsuleper 25 days)Tier 2M90; QL (8 capsulesper 25 days)Aprepitant Oral Capsule 80 MGEmendApri 0M90AptiomTier 2M90Aptivus Oral CapsuleTier 2QL (120 EA per 30days)Aptivus Oral SolutionTier 2QL (300 ml/30 days)Tier 2M90Aqua Glycolic Hand/BodyTier 2M90Aqua LactenTier 2M90Aquaderm Treatment/MoisturizerTier 2M90AquamedTier 2M90Aralast NP Intravenous SolutionReconstituted 1000 MG, 500 MGTier 2PA; SP; DualAP-ZelABC Plus SeniorAranelle 0M90Aranesp (Albumin Free) InjectionSolution 10 MCG/0.4MLTier 2PA; SPAranesp (Albumin Free) InjectionSolution 100 MCG/ML, 200 MCG/ML,25 MCG/ML, 300 MCG/ML, 40MCG/ML, 60 MCG/MLTier 2PA; SP; DualAranesp (Albumin Free) InjectionSolution Prefilled SyringeTier 2PA; SP; DualArbinoxa Oral TabletTier 2M90ArcalystTier 2PA; SP; Dual; QL (8VIALS per 28 days)Arcapta NeohalerTier 2M90Tier 2PA; QL (60 ML per 30days)Argyle Sterile SalineTier 2M90ARIPiprazole Oral SolutionTier 2M90; QL (150ml permonth)ARIPiprazole Oral Tablet 10 MG, 2 MG,Abilify5 MGTier 2M90; QL (60 EA per30 days)ARIPiprazole Oral Tablet 15 MG, 20 MG,Abilify30 MGTier 2M90; QL (30 EA per90 days)Arformoterol TartrateBrovana11
Covered ProductReferenceTier Status NotesARIPiprazole Oral Tablet DispersibleTier 2M90; QL (30 EA per90 days)Aristada InitioTier 2PD; QL (1 SYR per 30days)Aristada Intramuscular Prefilled Syringe1064 MG/3.9MLTier 2PD; QL (1 SYR per 60days)Aristada Intramuscular Prefilled Syringe441 MG/1.6ML, 662 MG/2.4ML, 882MG/3.2MLTier 2PD; QL (1 SYR per 30days)Armodafinil Oral Tablet 150 MG, 200MG, 250 MGNuvigilTier 2PA; QL (30 EA per 90days)Armodafinil Oral Tablet 50 MGNuvigilTier 2PA; QL (60 EA per 30days)Armour Thyroid Oral Tablet 120 MG, 180MG, 240 MG, 300 MGTier 2M90Arnuity Ellipta Inhalation Aerosol PowderBreath Activated 100 MCG/ACT, 50MCG/ACTTier 2PAArnuity Ellipta Inhalation Aerosol PowderBreath Activated 200 MCG/ACTTier 2PA; M90Arranon 0Arsenic Trioxide Intravenous Solution 12TrisenoxMG/6ML 0M90Arthritis PainMidolTier 2M90Arthritis Pain Relief OralMidolTier 2M90Arthritis Pain Reliever OralMidolTier 2M90Tier 2M90Artificial Tears Ophthalmic Solution 1.4%Arzerra 0AscenivTier 2PA; SP; DualAscomp-CodeineTier 2M90Tier 2QL (60 EA per 30days)Asenapine MaleateAshlynaSaphrisSP 0M90Asmanex (120 Metered Doses)Tier 2M90Asmanex (14 Metered Doses)Tier 2M90Asmanex (30 Metered Doses)Tier 2M90Asmanex (60 Metered Doses)Tier 2M90Asmanex (7 Metered Doses)Tier 2M90Asmanex HFA Inhalation Aerosol 100MCG/ACT, 200 MCG/ACTTier 2M9012
Covered ProductReferenceTier Status NotesAsmanex HFA Inhalation Aerosol 50MCG/ACTTier 2Aspirin-Caff-DihydrocodeineTier 2M90; QL (300capsules per 30 days.Click;HERE)Aspirin-Dipyridamole ERTier 2M90Tier 2M90Tier 2SPAspirtab Maximum StrengthBayer Advanced AspirinEx StAstagraf XLAtazanavir SulfateReyatazTier 2SPAtenolol OralTenorminTier 1M90Atenolol-ChlorthalidoneTenoretic 100Tier 1M90Athletes Foot Spray External AerosolTinactinTier 2M90Atomoxetine HClStratteraTier 2STAtorvastatin Calcium OralLipitorTier 2M90; QL (30 EA per90 days)Atovaquone OralMepronTier 2M90Atovaquone-Proguanil HClMalaroneTier 2M90Atropine Sulfate Injection Solution 0.4MG/ML, 1 MG/MLTier 2M90Atropine Sulfate Ophthalmic OintmentTier 2M90Atropine Sulfate Ophthalmic Solution 1 % Isopto AtropineTier 2M90Atrovent HFATier 2M90AubagioTier 2PA; SP; QL (30 EAper 90 days)AubraAugmentin Oral Suspension Reconstituted125-31.25 MG/5ML 0M90Tier 2M90Tier 2M90Auraphene-BMurine EarAurora Pen NeedlesAdvocate Insulin PenNeedles 0M90Aurora Unifine PentipsAdvocate Insulin PenNeedles 0M90AustedoTier 2PAAvandia Oral Tablet 2 MG, 4 MGTier 2ST; M90AvastinAVC VaginalAveed 0Tier 2MBPA; SP; DualM90PAAveeno Active Naturals DailyTier 2M90Aveeno Anti-Itch Max StTier 2M9013
Covered ProductReferenceTier Status NotesAveeno Daily Moisturizing ExternalLotionTier 2M90Aveeno Positively Ageless BodyTier 2M90Aveeno Stress ReliefTier 2M90 0M90AvidoxyTier 2M90Avita External CreamTier 2M90Avita External GelTier 2ST; M90AvonexTier 2SP; QL (4 SYR per 28days)Avonex Pen Intramuscular Auto-InjectorKitTier 2SP; QL (1 KIT per 28days)Avonex Prefilled Intramuscular PrefilledSyringe KitTier 2SP; QL (1 KIT per 28days)Tier 2M90AvsolaTier 2PA; SP; Dual; QL (5VIALS per 42 days)Ayr NasalTier 1M90AvianeAv-Phos 250 NeutralPhospha 250 NeutralAyvakit Oral Tablet 100 MG, 200 MG,300 MG 0QL (30 EA per 30days)Ayvakit Oral Tablet 25 MG 0QL (120 EA per 30days)Ayvakit Oral Tablet 50 MG 0QL (60 EA per 30days) 0SP; QL (QL Flag)AzaCITIDineVidazaAzasanTier 2M90AzaSiteTier 2M90azaTHIOprine Oral Tablet 50 MGImuranTier 2M90Azelaic Acid ExternalFinaceaTier 2STAzelastine HCl Nasal Solution 0.1 %, 0.15%Tier 2M90Azelastine HCl OphthalmicTier 2ST; M90; QL (6ml per25 days)AzelexTier 2ST; M90AzilectTier 2M90; QL (QL Flag)Azithromycin Oral SuspensionReconstitutedZithromaxTier 2M90Azithromycin Oral Tablet 250 MG, 500MGZithromaxTier 2M90Tier 2M90Azithromycin Oral Tablet 600 MG14
Covered ProductReferenceTier Status NotesB-6 (pyridoxine) TABLET 500 MGORALTier 2M90B6 NaturalTier 2M90Baby Ayr SalineTier 1M90Baby EaseTier 2M90Baby Super Daily D3 Oral Liquid 400UT/0.028MLBaby DdropsTier 2M90Baby Vitamin D3 Oral Liquid 400UT/0.028MLBaby DdropsTier 2M90Bacitracin ExternalBacitraycin PlusTier 2M90Tier 2M90Bacitracin OphthalmicBacitracin-Polymyxin B OphthalmicOintment 500-10000 UNIT/GMPolycinTier 2M90Bacitra-Neomycin-Polymyxin-HCNeo-Polycin HCTier 2M90Bacitraycin Plus External Ointment 500UNIT/GMTier 2M90Baclofen Oral Tablet 10 MG, 20 MGTier 2M90Bactroban NasalTier 2PA; M90BafiertamTier 2PA; SP; QL (120 EAper 30 days)Balcoltra 0Balsalazide DisodiumColazalTier 2M90Balversa Oral Tablet 3 MG 0PA; SP; QL (84 EAper 28 days)Balversa Oral Tablet 4 MG 0PA; SP; QL (56 EAper 28 days)Balversa Oral Tablet 5 MG 0PA; SP; QL (28 EAper 28 days)Balziva 0M90Banophen OralTier 2M90Banzel Oral Tablet 200 MGTier 2M90; QL (120 EA per30 days)Banzel Oral Tablet 400 MGTier 2M90; QL (240 tabletsper month)Baqsimi One PackTier 2PDBaqsimi Two PackTier 2PDBaraclude Oral SolutionTier 2SP; QL (QL Flag)Basaglar KwikPenTier 1PABasic AMABC Plus SeniorTier 2M90Basic PMABC Plus SeniorTier 2M90BavencioMBPA15
Covered ProductReferenceTier Status NotesBaxdela OralTier 2Bayer Advanced Aspirin Ex StTier 2M90Bayer Aspirin Extra StrengthTier 2M90Bayer Low Dose Oral Tablet ChewableTier 2M90Tier 2M90 0M90Tier 1M90BD AutoShield Duo 0M90BD Pen Needle Mini U/F 0M90BD Pen Needle Original U/F 0M90Tier 2M90Tier 2M90Tier 2PA; SPTier 2M90Bekyree 0M90Beleodaq 0SPBaza AntifungalTineacideBCG VaccineBD AutoShield 29G X 5MM , 29G X8MMBD PosiFlush IntravenousBeauty LotionA D Personal CareLotionBebulinBedding Spray Lice TreatmentRIDBelladonna Alkaloids-Opium RectalSuppository 16.2-60 MGTier 2BelsomraTier 2PA; QL (30 EA per 30days)Benazepril HCl OralLotensinTier 1M90Benazepril-hydroCHLOROthiazideLotensin HCTTier 1M90Bendeka 0BeneFIX Intravenous KitTier 2SPPA; SP; PD; DualBenlysta IntravenousMBPABenlysta Subcutaneous Solution AutoInjectorMBPA; QL (4 PENS per28 days)Benlysta Subcutaneous Solution PrefilledSyringeMBPA; QL (4 SYR per 28days)Bensal HPMG217 Psoriasis MultiSymptomTier 2M90BenzePrO Creamy WashTier 2M90BenznidazoleTier 2Benzoyl Peroxide Cleanser ExternalLotion 6 %Tier 2M90Tier 2M90Tier 2M90Benzoyl Peroxide External Gel 10 %Benzoyl Peroxide External Gel 2.5 %16Clean & Clear Persa-GelMax St
Covered ProductReferenceBenzoyl Peroxide External Gel 5 %Medpura BenzoylPeroxideTier 2M90Benzoyl Peroxide Wash External Liquid10 %Medpura BenzoylPeroxideTier 2M90Benzoyl Peroxide Wash Liquid 10 %External External Liquid 10 %Medpura BenzoylPeroxideTier 2M90Benztropine Mesylate OralTier 2M90BeovuTier 2PA; SP; DualBepreveTier 2ST; M90; QL (5ml per25 days)BerinertTier 2PA; SP; QL (QL Flag);DualBesivanceTier 2M90BesponsaMBBeta Care External LotionA D Personal CareLotionTier Status NotesPATier 2M90Tier 2M90Tier 2M90Betamethasone Dipropionate AugExternal GelTier 2ST; M90; QL (QLApplies)Betamethasone Dipropionate AugExternal LotionTier 2ST; M90; QL (QLApplies)Tier 2M90Betamethasone Dipropionate ExternalCreamTier 2M90Betamethasone Dipropionate ExternalLotionTier 2M90Betamethasone Dipropionate ExternalOintmentTier 2ST; M90; QL (QLApplies)Betamethasone Valerate External CreamTier 2M90Tier 2ST; QL (QL Applies)Betamethasone Valerate External LotionTier 2M90Betamethasone Valerate ExternalOintmentTier 2M90Betaseron Subcutaneous KitTier 2SP; QL (14 per 28days)Tier 2M90Betaxolol HCl OphthalmicTier 2M90Betaxolol HCl OralTier 1M90Bethanechol Chloride OralTier 2M90Betadine Ophthalmic PrepBetamethasone Dipropionate AugExternal CreamBetamethasone Dipropionate AugExternal OintmentBetamethasone Valerate External FoamBetaTemp ChildrensDiprolene AFDiproleneLuxiqPediaCare Children17
Covered ProductReferenceTier Status NotesBetimolTier 2M90Betoptic-STier 2M90Bevacizumab IntraocularTier 2PA; SPBevespi AerosphereTier 2BexaroteneTargretin 0SP; QL (QL Flag) 0M90 0M90Tier 2M90BiCNU 0M90BijuvaTier 2PABiktarvyTier 2PD; QL (30 EA per 30days)Tier 2M90Bimatoprost OphthalmicTier 2M90Bio GloTier 2M90BexseroBicalutamideCasodexBicarsim Oral Tablet 80 MGBimatoprost ExternalLatisseBiocalDEKAs PlusTier 2M90BiocelABC Plus SeniorTier 2M90Tier 2M90Tier 2M90Tier 2M90 0M90Tier 2M90Tier 2M90Bio-StatinBiosuppBProtected Multi-ViteBiotect Plus Oral LiquidBioThraxBiotin Plus/Calcium/Vit D3ABC Plus SeniorBisac-Evac RectalBisacodyl ECAlophenTier 2M90Bisacodyl Laxative RectalThe Magic BulletTier 2M90Bisacodyl RectalThe Magic BulletTier 2M90BiscolaxThe Magic BulletTier 2M90Bismatrol Oral SuspensionKaopectateTier 2M90Tier 1M90Bisoprolol Fumarate OralBisoprolol-HydrochlorothiazideZiacTier 1M90Bite-A-MinsBounty Bears/CTier 2M90Bite-A-Mins/IronLand Before TimeMultivitaminTier 2M90BivigamTier 2PA; SP; DualBlenrepMBBleo 15KPATier 1M90 0M90BlephamideTier 2M90Blephamide S.O.P.Tier 2M90Bleomycin Sulfate18
Covered ProductReferenceTier Status NotesBlincyto 0SPBlisovi 24 Fe 0M90Blisovi Fe 1.5/30 0M90Blisovi FE 1/20 0M90Tier 2M90Blis-To-Sol External LiquidBlood Pressure Monitor 7Body/Hair/Skin/Nails 0DEKAs PlusBonjestaBoostrix Intramuscular Suspension 5-2.518.5M90; QL (QL Flag);QL (1 EA per 3YEARs)Tier 2M90Tier 2PA; QL (60 EA per 30days) 0M90Tier 2M90Tier 2PA; SP; QL (60 EAper 30 days)Bosulif Oral Tablet 100 MG 0SP; PD; QL (90 EAper 30 days)Bosulif Oral Tablet 400 MG, 500 MG 0SP; PD; QL (30 EAper 30 days)BotoxTier 2PA; QL (QL Flag);DualBoudreauxs Butt PasteTier 2M90Bounty Bears/CTier 2M90BP 10-1Tier 2M90Boric Acid External GranulesBosentanTracleerBP Foaming WashMedpura BenzoylPeroxideTier 2M90BP Gel External Gel 10 %Clean & Clear Persa-GelMax StTier 2M90BP Gel External Gel 5 %Medpura BenzoylPeroxideTier 2M90BP Wash External Liquid 10 %Medpura BenzoylPeroxideTier 2M90BP Wash External Liquid 2.5 %PanOxylTier 2M90BP Wash External Liquid 7 %BenzePrO Creamy WashTier 2M90B-Plex PlusABC Plus SeniorTier 2M90BPO-10 WashMedpura BenzoylPeroxideTier 2M90BProtected Multi-ViteTier 2M90BProtected Pedia Iron 0M90Tier 2M90BProtected Pedia Poly-Vite/Fe19
Covered ProductReferenceBraftovi Oral Capsule 75 MGB-Redi/Red Hearts/Red Roosters 0ABC Plus SeniorBreo ElliptaBriellynBalzivaBrilintaBrimonidine Tartrate OphthalmicAlphagan PBrineuraBrinzolamideTier Status NotesTier 2M90Tier 2PA; M90; QL (1 EAper 30 days) 0M90Tier 2M90; QL (60 EA per30 days)Tier 2M90MBAzoptSP; QL (180 EA per 30days)PATier 2Bromfenac Sodium (Once-Daily)Tier 2ST; M90; QL (1.7mlper 25 days)Bromfenac Sodium OphthalmicTier 2ST; M90; QL (5ml per25 days)Tier 2M90Brompheniramine Tannate Oral TabletChewableTier 2M90BronchitolTier 2PA; QL (600 EA per30 days)Brukinsa 0PA; SP; QL (120 EAper 30 days)BucalsepTier 2M90Bromocriptine Mesylate OralParlodelBudesonide ER Oral Tablet ExtendedRelease 24 HourUcerisTier 2QL (112 tablets peryear (a rolling 365days))Budesonide InhalationPulmicortTier 2M90Tier 2ST; M90Tier 2M90Tier 1M90Tier 1M90BunavailTier 2PA; QL (60 EA per 30days)Buphenyl Oral TabletTier 2SP; QL (QL Flag)Budesonide NasalBudesonide OralEntocort ECBumetanide InjectionBumetanide OralBumexBupivacaine HCl (PF) Injection Solution0.75 %Sensorcaine-MPFTier 2M90Bupivacaine HCl Injection Solution 0.25%, 0.5 %SensorcaineTier 2M90Bupivacaine-Epinephrine InjectionSolution 0.25% -1:200000, 0.5% 1:200000Sensorcaine/EPINEPHrineTier 2M90Tier 2PA; M90Buprenex20
Covered ProductReferenceTier Status NotesBuprenorphine HCl Injection Solution 0.3BuprenexMG/MLTier 2PABuprenorphine HCl SublingualTier 2PA; QL (90 EA per 30days)Buprenorphine HCl-Naloxone HClSublingual Tablet SublingualTier 2PA; QL (60 EA per 30days)Tier 2ST; QL (4 patches per30 days)Buprenorphine TransdermalButransBuPROPion HCl ER (Smoking Det) 0M90buPROPion HCl ER (SR)Wellbutrin SRTier 2M90BuPROPion HCl ER (XL) Oral TabletExtended Release 24 Hour 150 MG, 300MGWellbutrin XLTier 2M90buPROPion HCl OralTier 2M90Buried Treasure Active 55 PlusTier 2M90busPIRone HCl OralTier 2M90BusulfexTier 1M90Butalbital-Acetaminophen Oral Tablet 50Tencon325 MGTier 2M90Butalbital-APAP-Caff-Cod Oral Capsule50-300-40-30 MGTier 2Fioricet/CodeineButalbital-APAP-Caff-Cod Oral Capsule50-325-40-30 MGTier 2M90Tier 2M90Butalbital-APAP-Caffeine Oral Tablet 50Bac325-40 MGTier 2M90Butalbital-ASA-Caff-CodeineTier 2Butalbital-APAP-Caffeine Oral ier 2Butalbital-Aspirin-Caffeine Oral CapsuleTier 2Butisol Sodium Oral Tablet 30 MGTier 2Butorphanol Tartrate InjectionTier 2Butorphanol Tartrate NasalTier 2Bydureon BCiseTier 2PABydureon Subcutaneous Pen-InjectorTier 2QL (4 pens per 28days)Byetta 10 MCG Pen SubcutaneousSolution Pen-InjectorTier 2BP; QL (2 pens per 28days)Byetta 5 MCG Pen Subcutaneous SolutionPen-InjectorTier 2BP; QL (1 pen per 28days)Bynfezia PenTier 2PA; SP; Dual; QL (6PENS per 30 days)CabenuvaMBM90PD21
Covered ProductReferenceTier Status NotesCabergolineTier 2M90CabliviTier 2PA; SP; DualCabometyx 0PA; SP; QL (30 EAper 30 days)Caffeine Citrate Or
MassHealth. Pharmacy Formulary. INTRODUCTION AllWays Health Partners. covers a wide variety of safe and effective medications for treating our members' medical needs. This list of AllWays Health Partners’ covered medications shows the tier in which medications are placed. You can use this
