Clinical Criteria
CVS Caremark develops clinical criteria to determine medical necessity for certain medications or therapeutic classes. The criteria help decide what medication, treatment, or supply will be covered for Blue Cross Blue Shield of Massachusetts members who have a health plan that uses the Standard Control with Advanced Control Specialty Formulary. These are general guidelines. Not all medications are covered by all prescription plans. An individual member’s coverage depends on their plan benefits, including the formulary and their eligibility. Check your benefit materials for details.
CVS Caremark guidelines are reviewed annually and are updated as needed when new safety or medical evidence is available. We post them quarterly to this site. They are developed with input from providers that have relevant clinical expertise. CVS Caremark guidelines also follow accreditation standards.
Exception Criteria
For certain medications that are not on the formulary, members must also meet additional exception criteria. The exception criteria are located on the Exception Criteria tab.
Select the first letter of the medication name to find the criteria we use to determine coverage. Drug coverage is dependent on the member’s formulary and their eligibility.
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Content updates last made on: June 18, 2025
CaremarkPCS Health, LLC (“CVS Caremark”) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Exception Criteria
CVS Caremark develops clinical criteria to determine medical necessity for certain medications or therapeutic classes. The criteria help decide what medication, treatment, or supply will be covered for Blue Cross Blue Shield of Massachusetts members who have a health plan that uses the Standard Control with Advanced Control Specialty Formulary. These are general guidelines. Not all medications are covered by all prescription plans. An individual member’s coverage depends on their plan benefits, including the formulary and their eligibility. Check your benefit materials for details.
CVS Caremark guidelines are reviewed annually and are updated as needed when new safety or medical evidence is available. We post them quarterly to this site. They are developed with input from providers that have relevant clinical expertise. CVS Caremark guidelines also follow accreditation standards.
Exception Criteria
For certain medications that are not on the formulary, members must also meet additional exception criteria. The exception criteria are located on the Exception Criteria tab.
A
B
C
D
E
F
G
H
I
J
K
L
M
O
P
Q
R
S
T
U
V
W
X
Y
Content updates last made on: June 18, 2025
CaremarkPCS Health, LLC (“CVS Caremark”) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.