UPDATE - Effective July 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary
Effective July 1, 2023, CVS Caremark®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Switch tiers
- Have new quantity or dosing limits
- Require prior authorization and/or step therapy
- Be added to the list of covered medications
- Be designated as preferred
To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.
UPDATE - Effective July 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates
Effective July 1, 2023, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´1 plans with a three-tier pharmacy benefit. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Have new quantity or dosing limits
- Switch tiers
- Require prior authorization and/or step therapy
- No longer be covered under the medical benefit and will only be covered under the pharmacy benefit
We're also making medical policy changes, effective July 1, 2023.
1. This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Medications No Longer Covered Starting July 1, 2023
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.
| Medication Class | Medication Name | Covered Alternative |
|---|---|---|
|
Topical Anti-psoriatic |
calcipotriene - betamethasone dipropionate topical suspension |
clobetasol shampoo
|
|
Prenatal Vitamins |
Atabex EC |
Elite OB tab |
Medications with New Quality Care Dosing (QCD) Limit
After carefully reviewing each medication’s cost, its clinically appropriate covered alternatives, and the FDA-approved label dosage guidelines, we’re adding QCD limits to the medication(s) listed below on our formulary. However, a doctor may request a QCD exception if the quantity being requested for coverage is medically necessary.
| Medication Class | Medication Name | New Coverage Limit |
| Tetracycline Antibiotic |
Nuzyra 150 mg Tablet ONLY |
30 tables per 30 days |
Medications Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower tier under certain pharmacy plans, and what members pay for the following medications may decrease.
| Medication Class | Medication Name | 2023 Tier | |||
|---|---|---|---|---|---|
| For members with a three-tier pharmacy benefit |
For members with a four-tier pharmacy benefit |
For members with a five-tier pharmacy benefit |
For members with a six-tier pharmacy benefit |
||
| Monoclonal Antibodies | Nucala2 | Tier 2a | Tier 3b | Tier 4c | Tier 5d |
| Xolair2 | Tier 2a | Tier 3b | Tier 4c | Tier 5d | |
2. This medication also has prior authorization and/or step therapy requirements.
- This medication was previously covered at Tier 3.
- This medication was previously covered at Tier 4.
- This medication was previously covered at Tier 5.
- This medication was previously covered at Tier 6.
Coverage Changes for Certain Medications Moving from Our Medical to Pharmacy Benefit
Effective July 1, 2023, coverage for the following specialty medications will move out of our medical benefit and only be included under our pharmacy benefit. These medications will also only be covered when filled at an in-network specialty pharmacy. This change will apply to all medical plans, except Medicare Advantage, Medical Supplemental plans, and Federal Employee Program plans.
- Ilumya
- Skyrizi
Members who are currently filling these specialty medications at an in-network specialty pharmacy under their pharmacy benefit won’t experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit. Members who are currently filling these medications under their medical benefit and have pharmacy coverage with Blue Cross Blue Shield of Massachusetts will receive a detailed letter about the coverage change, along with next steps. Members who don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts will also receive a letter about the change, with additional information about contacting their prescription plan to find out if they’re covered for these medications.
Medical Policy Updates
Blue Cross medical policies are developed by using evidence-based information to define the technologies, procedures, and treatments that are considered medically necessary, or not medically necessary, or investigational. We use pharmacy medical policies to describe how we cover certain medications. The policies listed below are being updated. Changes include:
- Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
- Prior authorization requirements for specific medications to ensure the prescribing doctor has determined that a medication is necessary to treat a member, based on specific medical standards.
| For this Policy | Update |
| Immune Modulating Drugs Policy (004) |
This policy will be updated to reflect the medical to pharmacy benefit coverage change for Ilumya and Skyrizi as noted below in the Injectable Specialty Medication Coverage Policy (071). |
| Immunomodulators for Skin Conditions Policy (010) |
Rinvoq coverage criteria will be updated to require the use of another systemic medication other than Dupixent, before it’s covered.
|
| Injectable Asthma Medications Policy (017) |
A prescription by a specialist will no longer be required in order for Xolair to be covered. Prior authorization will be required for new prescriptions. |
| Injectable Specialty Medication Coverage Policy (071) | Ilumya and Skyrizi will be added to this policy. These medications will be covered only under the pharmacy benefit starting July 1, 2023 and prior authorization will be required for new prescriptions. |
| Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033) | Step therapy requirements will be updated to require the use of a steroid and tacrolimus or pimecrolimus, before covering Dupixent (when used to treat atopic dermatitis, also known as eczema). |
Looking for More Information?
For more information about any of these medications, go to the Medication Lookup tool.
Questions?
If you have any questions, contact your account executive.
Quality Care Dosing Limits Have Increased for Select Medications
To give doctors greater flexibility when prescribing certain controlled substances, we’ve doubled the quality care dosing limit for the medications listed below. The change took effect on April 12, 2023, and applies to plans that have pharmacy coverage through Blue Cross Blue Shield of Massachusetts and use the Blue Cross formulary.
The following medications increased coverage to 60 units for a 30-day supply:
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 5MG ER
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 10MG ER
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 15MG ER
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 25MG ER
- METHYLPHENIDATE TAB 18MG ER
- METHYLPHENIDATE TAB 27MG ER
- METHYLPHENIDATE TAB 54MG ER
The following medications increased coverage to 120 units for a 30-day supply:
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 20MG ER
- AMPHETAMINE/DEXTROAMPHETAMINE CAP 30MG ER
- METHYLPHENIDATE TAB 36MG ER
If you have any questions, contact your account executive.
New Neonatal Intensive Care Unit (NICU) Program Begins September 1, 2023
Starting September 1, 2023, we’ll be working with ProgenyHealth®´, an independent health care company dedicated to maternity and infant health, to provide Neonatal Intensive Care Unit (NICU) utilization management and care management services for eligible commercial members.
ProgenyHealth will manage the NICU level-of-care review process and provide comprehensive care management services to babies cared for in the NICU or special care nursery, and for the first year of their life. Babies born prior to September 1, 2023, who were cared for in the NICU, may have their care managed by ProgenyHealth, depending on the level of care. We’ll manage the transition to this program.
Benefits of the program include:
- A dedicated team of specialists from ProgenyHealth that works with the infant’s care team to improve outcomes, and evaluate external issues that may affect the baby’s health.
- Additional clinical support for the baby’s family that supports a safe discharge.
- A dedicated care manager who provides support and education.
- An on-call staff member who’s available 24/7.
Additional prior authorizations won’t be required as inpatient NICU services already require authorizations.
If you have any questions, contact your account executive.
Introducing Blue 20/20 PLUS: Enhanced Vision Care
Starting July 1, 2023, with the new Blue 20/20 PLUS enhanced coverage (part of Blue 20/20’s portfolio expansion), members can get greater savings on their vision care. Members receiving care from PLUS providers, who are already a part of our Blue 20/20 provider networks, will get the following enhanced benefits:
- $0 exam copay
- Additional $50 frame allowance, with no brand restrictions
In addition, these benefits can be combined with other offers and discounts to provide even greater savings and a seamless member experience.
Learn more about Blue 20/20 PLUS here.
Questions?
If you have any questions, contact your account executive.
Preventive Care Mammograms for Adult Commercial Members at Any Age
All HMO and PPO plan members are covered for at least one preventive-care mammogram screening per year, without age restriction, when ordered by a provider. This benefit is $0 for members of commercial HMO/POS, EPO/PPO, and indemnity plans.
Diagnostic imaging — as opposed to imaging for preventive-care purposes — is subject to deductible, copayment, and/or co-insurance.
Members should speak to their doctor about the mammogram schedule that’s right for them.
Application of this benefit and the associated cost share continues to be aligned with other plan preventive health screening services. The benefit and its cost-share are also in accordance with National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, and they comply with the Patient Protection and Affordable Care Act.
Effective July 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary
Effective July 1, 2023, CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Switch tiers
- Have new quantity or dosing limits
- Require prior authorization and/or step therapy
- Be added to the list of covered medications
- Be designated as preferred
Complete details about these changes will be available by May 24, 2023 in the What’s New section.
Effective July 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates
Effective July 1, 2023, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Be excluded from coverage (exceptions won’t be granted)
- Switch tiers
- Require prior authorization and/or step therapy
- No longer be covered under the medical benefit and will only be covered under the pharmacy benefit
We’re also making medical policy changes, effective July 1, 2023.
Complete details about these changes will be available by May 24, 2023 in the What’s New section.
*This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
UPDATE - Effective April 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary
Effective April 1, 2023, CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Switch tiers
- Have new quantity or dosing limits
- Require prior authorization and/or step therapy
- Be added to the list of covered medications
- Be designated as preferred
To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.
Change in Prior Authorization Requirements for Certain Musculoskeletal Services
As shared in Q4 2022, we're updating our prior authorization requirements for certain musculoskeletal (MSK) services for all HMO and PPO plan members*. These changes will go into effect on April 1, 2023. We'll review requests according to evidence-based medical necessity criteria to help ensure that members are receiving safe, effective, and medically necessary MSK services. Throughout their MSK treatment, appropriate members will be offered support from our Care Managers.
In- and out-of-network providers will need to submit prior authorization requests for members receiving ongoing treatments for specified joint, spine, and pain management, and for members who begin treatment on or after April 1, 2023.
If you have questions, contact your account executive.
* For the full list of services, members should check their plan details or call Member Service.
Mental Health Treatment: Prior Authorization Changes
We’ve removed prior authorization requirements for Intensive Community-Based Treatment (ICBAT), Community-Based Acute Treatment (CBAT), and inpatient psychiatric treatment, consistent with the Massachusetts Chapter 177 of the Acts of 2022, an act aimed at addressing barriers to care for mental health. Moving forward, prior authorization from any provider (both in and out-of-network) is not required to determine medical necessity for these mental health services.
However, this doesn’t change the level of out-of-network benefits or associated cost-sharing detailed in the member’s plan benefits. This mandate also applies to out-of-state, inpatient psychiatric treatment.
Although this state mandate does not apply to self-insured accounts (ASCs), Blue Cross applies the same utilization review and prior authorization requirements to all members. This change aligns with our ongoing commitment to improve access to mental health care.
If you have any questions, contact your account executive.
Effective April 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary
Effective April 1, 2023, CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Switch tiers
- Have new quantity or dosing limits
- Require prior authorization and/or step therapy
- Be added to the list of covered medications
- Be designated as preferred
Complete details about these changes will be available by February 24, 2023 in the What’s New section.
UPDATE - Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts.
CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF.
To see the 2023 SC-ACSF medication lists, go to the Medication Lookup tool.
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.
Effective January 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary
Effective January 1, 2023, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Be excluded from coverage (exceptions won’t be granted)
- Switch tiers
- Require prior authorization and/or step therapy
*This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Medications No Longer Covered Starting January 1, 2023
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.
| Medication Class | Medication Name | Covered Alternative |
|---|---|---|
|
Antidiabetic — |
Kombiglyze XR1 Onglyza1 |
Glyxambi1 Janumet1 Janumet XR1 Januvia1 Trijardy XR1 |
|
Antidiabetic — |
Bydureon1 Bydureon BCise1 Byetta1 |
Ozempic1 Trulicity1 Victoza1 |
| Inflammatory Conditions |
Actemra1,2.3 Actemra ACTPen1,2,3 Cimzia1,2 Ilumya1,2 Kineret1,2 Olumiant1,2 Orencia1,2 Orencia ClickJect1,2 Siliq1,2 Simponi1,2 |
Enbrel1 Humira1 Kevzara1 Otezla1 Rinvoq ER1 Skyrizi1 Stelara1 Taltz1 Tremfya1 Xeljanz1 Xeljanz XR1 |
|
Migraine Treatment —Calcitonin Gene-Related Peptide (CGRP) |
Qulipta1,2 Vyepti1,2,3 |
Aimovig1 Ajovy1 Emgality1 Nurtec1 |
| Multiple Sclerosis Treatment | Bafiertam1,2,3 | dimethyl fumarate |
- This medication also has prior authorization and/or step therapy requirements.
- Members currently using this medication will continue to be covered until their prior authorization expires.
- Members using this medication will experience a copay increase as of January 1, 2023.
Medications Excluded from Coverage
Certain medications will be excluded from our pharmacy benefit, effective January 1, 2023. Members will be responsible for the full cost of these medications when filling a prescription at the pharmacy. This change will apply to all commercial plans, group Medex®´plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications. We’ll contact members who will be affected by this change.
To find out if a medication is excluded from coverage, effective January 1, 2023, use the Medication Lookup tool.
Medications Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease. This isn’t a complete list of medications switching tiers, and we’ll contact members who will be affected by this change.
To find out which tier a medication is in, effective January 1, 2023, use the Medication Lookup tool.
| Medication Class | Medication Name | 2023 Tier | |||
|---|---|---|---|---|---|
| For members with a three-tier pharmacy benefit |
For members with a four-tier pharmacy benefit |
For members with a five-tier pharmacy benefit |
For members with a six-tier pharmacy benefit |
||
| Antidiabetic — GLP1 Receptor Antagonists (injectable) |
Ozempic* Victoza* |
Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Antidiabetic — GLP1 Receptor Antagonist (oral) | Rybelsus* | Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Antiobesity (injectable) |
Contrave XR* Saxenda* |
Tier 2a | Tier 3b | Tier 2a | Tier 3b |
| Irritable Bowel Syndrome Treatment (oral) | Xifaxan* | Tier 3e | Tier 4e | Tier 3e | Tier 4e |
| Multiple Sclerosis Treatment | Aubagio* | Tier 2a | Tier 3b | Tier 4c | Tier 5d |
| Vumerity* | Tier 2e | Tier 3e | Tier 4e | Tier 5e | |
* This medication also has prior authorization and/or step therapy requirements.
- This medication was previously covered at Tier 3.
- This medication was previously covered at Tier 4.
- This medication was previously covered at Tier 5.
- This medication was previously covered at Tier 6.
- This medication was previously non-covered.
Medical Policy Updates
Blue Cross medical policies are developed by using evidence-based information to define the technologies, procedures, and treatments that are considered medically necessary, or not medically necessary, or investigational. We use pharmacy medical policies to describe how we cover certain medications. We’re updating the policies listed below. These changes include:
- Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
- Prior authorization requirements for specific medications to ensure the prescribing doctor has determined that a medication is necessary to treat a member, based on specific medical standards.
| For this Policy | Update |
| Anti-Migraine Policy (021) |
Qulipta and Vyepti are moving from covered to non-covered. Prior authorization requirements will still apply. Members currently using these medications will continue to be covered until their prior authorization expires. The prescription lookback period for step therapy is changing for members who are newly prescribed the following medications: Aimovig, Ajovy, and Emgality. |
| Diabetes Step Therapy (041) |
Bydureon, Bydureon BCise, Byetta, Kombiglyze XR, and Onglyza are moving from covered to non-covered. As a result, these medications will move from Step 2 to Step 3 within this policy. New prior authorization is required for members currently taking these medications, and members who are newly prescribed these medications. Ozempic, Rybelsus, and Victoza are moving from non-covered to covered. As a result, these medications will move from Step 3 to Step 2 within this policy. |
| Immune Modulating Drugs (004) |
All medications in this policy will move from indication-based prior authorization to non-indication-based prior authorization. Preferred medications must be used before non-preferred medications will be approved and covered. Actemra, Actemra ACTPen, Cimzia, Ilumya, Kineret, Olumiant, Orencia, Orencia ClickJect, Siliq, and Simponi are moving from covered to non-covered. Members currently using these medications will continue to be covered until their prior authorization expires. Some members currently using these medications will experience an increase in out-of-pocket costs. Prior authorization is required for members who are newly prescribed these medications. |
| Drug Management and Retail Pharmacy Prior Authorization Policy (049) | Xifaxan will move from non-covered to covered. Prior authorization requirements will be required to check against Food and Drug Administration requirements. Members currently using these medications will continue to be covered until their prior authorization expires. |
| Multiple Sclerosis Step Therapy (839) | Prior authorization will be required for the following medications, to check against Food and Drug Administration requirements: Aubagio, Gilenya, Mavenclad, Mayzent, Vumerity, and Zeposia. |
Looking for More Information?
For more information about any of these medications, go to the Medication Lookup tool.
Questions?
If you have any questions, contact your account executive.
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts.
CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF.
The list of covered medications under the SC-ACSF will be available by October 24, 2022, in the What’s New section.
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.
UPDATE - Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts.
CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF.
To see the 2023 SC-ACSF medication lists, go to the Medication Lookup tool.
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.
Effective January 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary
Effective January 1, 2023, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Be excluded from coverage (exceptions won’t be granted)
- Switch tiers
- Require prior authorization and/or step therapy
*This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Medications No Longer Covered Starting January 1, 2023
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.
| Medication Class | Medication Name | Covered Alternative |
|---|---|---|
|
Antidiabetic — |
Kombiglyze XR1 Onglyza1 |
Glyxambi1 Janumet1 Janumet XR1 Januvia1 Trijardy XR1 |
|
Antidiabetic — |
Bydureon1 Bydureon BCise1 Byetta1 |
Ozempic1 Trulicity1 Victoza1 |
| Inflammatory Conditions |
Actemra1,2.3 Actemra ACTPen1,2,3 Cimzia1,2 Ilumya1,2 Kineret1,2 Olumiant1,2 Orencia1,2 Orencia ClickJect1,2 Siliq1,2 Simponi1,2 |
Enbrel1 Humira1 Kevzara1 Otezla1 Rinvoq ER1 Skyrizi1 Stelara1 Taltz1 Tremfya1 Xeljanz1 Xeljanz XR1 |
|
Migraine Treatment —Calcitonin Gene-Related Peptide (CGRP) |
Qulipta1,2 Vyepti1,2,3 |
Aimovig1 Ajovy1 Emgality1 Nurtec1 |
| Multiple Sclerosis Treatment | Bafiertam1,2,3 | dimethyl fumarate |
- This medication also has prior authorization and/or step therapy requirements.
- Members currently using this medication will continue to be covered until their prior authorization expires.
- Members using this medication will experience a copay increase as of January 1, 2023.
Medications Excluded from Coverage
Certain medications will be excluded from our pharmacy benefit, effective January 1, 2023. Members will be responsible for the full cost of these medications when filling a prescription at the pharmacy. This change will apply to all commercial plans, group Medex®´plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications. We’ll contact members who will be affected by this change.
To find out if a medication is excluded from coverage, effective January 1, 2023, use the Medication Lookup tool.
Medications Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease. This isn’t a complete list of medications switching tiers, and we’ll contact members who will be affected by this change.
To find out which tier a medication is in, effective January 1, 2023, use the Medication Lookup tool.
| Medication Class | Medication Name | 2023 Tier | |||
|---|---|---|---|---|---|
| For members with a three-tier pharmacy benefit |
For members with a four-tier pharmacy benefit |
For members with a five-tier pharmacy benefit |
For members with a six-tier pharmacy benefit |
||
| Antidiabetic — GLP1 Receptor Antagonists (injectable) |
Ozempic* Victoza* |
Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Antidiabetic — GLP1 Receptor Antagonist (oral) | Rybelsus* | Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Antiobesity (injectable) |
Contrave XR* Saxenda* |
Tier 2a | Tier 3b | Tier 2a | Tier 3b |
| Irritable Bowel Syndrome Treatment (oral) | Xifaxan* | Tier 3e | Tier 4e | Tier 3e | Tier 4e |
| Multiple Sclerosis Treatment | Aubagio* | Tier 2a | Tier 3b | Tier 4c | Tier 5d |
| Vumerity* | Tier 2e | Tier 3e | Tier 4e | Tier 5e | |
* This medication also has prior authorization and/or step therapy requirements.
- This medication was previously covered at Tier 3.
- This medication was previously covered at Tier 4.
- This medication was previously covered at Tier 5.
- This medication was previously covered at Tier 6.
- This medication was previously non-covered.
Medical Policy Updates
Blue Cross medical policies are developed by using evidence-based information to define the technologies, procedures, and treatments that are considered medically necessary, or not medically necessary, or investigational. We use pharmacy medical policies to describe how we cover certain medications. We’re updating the policies listed below. These changes include:
- Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
- Prior authorization requirements for specific medications to ensure the prescribing doctor has determined that a medication is necessary to treat a member, based on specific medical standards.
| For this Policy | Update |
| Anti-Migraine Policy (021) |
Qulipta and Vyepti are moving from covered to non-covered. Prior authorization requirements will still apply. Members currently using these medications will continue to be covered until their prior authorization expires. The prescription lookback period for step therapy is changing for members who are newly prescribed the following medications: Aimovig, Ajovy, and Emgality. |
| Diabetes Step Therapy (041) |
Bydureon, Bydureon BCise, Byetta, Kombiglyze XR, and Onglyza are moving from covered to non-covered. As a result, these medications will move from Step 2 to Step 3 within this policy. New prior authorization is required for members currently taking these medications, and members who are newly prescribed these medications. Ozempic, Rybelsus, and Victoza are moving from non-covered to covered. As a result, these medications will move from Step 3 to Step 2 within this policy. |
| Immune Modulating Drugs (004) |
All medications in this policy will move from indication-based prior authorization to non-indication-based prior authorization. Preferred medications must be used before non-preferred medications will be approved and covered. Actemra, Actemra ACTPen, Cimzia, Ilumya, Kineret, Olumiant, Orencia, Orencia ClickJect, Siliq, and Simponi are moving from covered to non-covered. Members currently using these medications will continue to be covered until their prior authorization expires. Some members currently using these medications will experience an increase in out-of-pocket costs. Prior authorization is required for members who are newly prescribed these medications. |
| Drug Management and Retail Pharmacy Prior Authorization Policy (049) | Xifaxan will move from non-covered to covered. Prior authorization requirements will be required to check against Food and Drug Administration requirements. Members currently using these medications will continue to be covered until their prior authorization expires. |
| Multiple Sclerosis Step Therapy (839) | Prior authorization will be required for the following medications, to check against Food and Drug Administration requirements: Aubagio, Gilenya, Mavenclad, Mayzent, Vumerity, and Zeposia. |
Looking for More Information?
For more information about any of these medications, go to the Medication Lookup tool.
Questions?
If you have any questions, contact your account executive.
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered
Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts.
CVS Caremark®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF.
The list of covered medications under the SC-ACSF will be available by October 24, 2022, in the What’s New section.
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.
What’s New for 2023
Choosing the right health plan is essential to attracting and retaining top talent. Effective January 1, 2023, and upon renewal, we’re enhancing our health plan offering to not only meet ongoing requirements but also the market demand to provide high-quality, more affordable coverage you expect from Blue Cross.
In 2023, we’ll offer:
- Solutions that drive value and address affordability
- Virtual Care Team – a new feature in most of our plans at no additional cost providing members a coordinated, virtual primary care experience
- New plans designed for lower premiums
- New Pharmacy Benefit Manager to help:
- Keep pharmacy costs down for accounts and members
- Provide more in-network pharmacy locations
- Offer new pharmacy programs that drive better health outcomes for members
For more details on these new offerings, read the 2023 Product Brochures.
Accounts with 50 or Fewer Enrolled
Accounts with 100 or More Enrolled
You can also use our Plan Comparison tool to find, compare, and download plan documents.
Questions?
If you have any questions, please contact your account executive.
UPDATE - Effective July 1, 2022, Medications No Longer Covered Under the National Preferred Formulary
Effective July 1, 2022, Express Scripts, Inc.®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for medical plans with the National Preferred Formulary (NPF). Included in this update are medications that will no longer be covered under the NPF.
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, Express Scripts is removing medications from their formulary. However, a doctor may request an exception if these medications are medically necessary. If the exception is approved by Blue Cross, the member will pay the highest-tier cost.
Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Pharmacy Medical Policy Updates
Effective July 1, 2022, we’re updating the Blue Cross Blue Shield of Massachusetts formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´ plans with a three-tier pharmacy benefit.* As part of the formulary update, certain medications are switching tiers.
We’ve also discontinued a medical policy as of March 1, 2022, and we’re making additional medical policy changes on April 1, 2022 and July 1, 2022.
*This doesn’t include Medex 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Medications Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease.
| Medication Class | Medication Name | 2022 Tier | |||
|---|---|---|---|---|---|
| For members with a three-tier pharmacy benefit |
For members with a four-tier pharmacy benefit |
For members with a five-tier pharmacy benefit |
For members with a six-tier pharmacy benefit |
||
| Inflammatory Conditions | Avsola | Tier 2a | Tier 3b | Tier 4c | Tier 5d |
| Neulasta | Tier 2a | Tier 3b | Tier 4c | Tier 5d | |
| Ziextenzo | Tier 2a | Tier 3b | Tier 4c | Tier 5d | |
- This medication was previously covered at Tier 3.
- This medication was previously covered at Tier 4.
- This medication was previously covered at Tier 5.
- This medication was previously covered at Tier 6.
Pharmacy Medical Policy Updates
Pharmacy medical policies are evidence-based documents that we develop to define the technologies, procedures, and treatments that are considered medically necessary; not medically necessary; and investigational. We use pharmacy medical policies to describe how we cover certain medications. We’re updating the following policies:
| Policies | Update | Date of Change |
| Dificid (fidaxomicin) (700) | This step therapy policy has been discontinued. We no longer require members to have prior treatment or failure with vancomycin before covering Dificid (fidaxomicin). Members who have an approved exception to cover Dificid (fidaxomicin) don’t need their doctors to renew this request. |
3/1/2022 |
| Immune Modulating Drugs (004) | Avsola will move from non-preferred to preferred within the Remicade and infliximab biosimilars policy section. Inflectra and Avsola will now be the preferred medications in this policy. |
4/1/2022 |
| Quality Care Cancer Program (Medical Oncology) (099) Nononcologic Uses of Rituximab (123) |
Riabni will move from non-preferred to preferred. Truxima will move from preferred to non-preferred. Ruxience and Riabni will now be the preferred medications in these policies. Members currently using Truxima will have continued coverage so their care isn’t disrupted. |
7/1/2022 |
| Quality Care Cancer Program (Medical Oncology) (099) | Herzuma, Ogivri, and Ontruzant will move from preferred to non-preferred. Kanjinti and Trazimera continue to be the preferred medications in this policy. Members currently using Herzuma, Ogivri, or Ontruzant will have continued coverage so their care isn’t disrupted. Providers who request prior authorization for Herzuma, Ogivri, and Ontruzant will need to go through AIM Specialty Health. |
7/1/2022 |
| Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033) Supportive Care Treatments for Patients with Cancer (105) |
Udenyca will move from preferred to non-preferred. Neulasta and Ziextenzo will move from non-preferred to preferred. Fulphila, Neulasta, and Ziextenzo will now be the preferred medications listed in these policies. Members currently using Udenyca will have continued coverage so their care isn’t disrupted. |
7/1/2022 |
Learn More About Medications
Use the Medication Lookup tool to learn more about coverage for these medications.
Questions?
If you have any questions, contact your account executive.
Effective July 1, 2022, Medications No Longer Covered Under the National Preferred Formulary
Effective July 1, 2022, Express Scripts, Inc.®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for medical plans with the National Preferred Formulary (NPF). Included in this update are medications that will no longer be covered under the NPF.
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, Express Scripts is removing medications from their formulary. However, a doctor may request an exception if these medications are medically necessary. If the exception is approved by Blue Cross, the member will pay the highest-tier cost.
Complete details about these changes will be available by April 26, 2022 in the What’s New section.
Update on Coverage Change for Infused, Injectable Medications Under the Medical Benefit, Effective January 1, 2022
We previously notified you that we planned to change the covered sites of service where members can have their infused or injectable medications administered. We’ve decided to make Site of Care a voluntary program rather than a requirement.
Voluntary Site of Care Program
The Voluntary Site of Care Program is designed to promote the use of infused and injected medications in the most cost-effective, clinically appropriate setting. Making this a voluntary program gives members a choice of where they receive their care.
We believe that our Voluntary Site of Care Program is clinically sound, safe, and cost-effective for most of our members, and that other health risks are mitigated when care is provided at alternate sites.
What This Means for Your Employees’ Coverage
- Members will continue to need authorization for the medications listed below. These already required authorization when covered under the member’s medical benefits.
- Members who wish to switch to an alternate site of service can work with their physicians and clinicians to transfer their care to a home infusion therapy provider in our network, if it’s clinically appropriate and with an approved authorization. We’re working with our network home infusion therapy providers to make this a smooth transition for members.
The Voluntary Site of Care Program will apply to all medical plans except for the following plan types:
- - Federal Employee Program
- - Indemnity
- - Managed Blue for Seniors
- - Medex®´
- - Medicare Advantage
| Medications That Currently Require Prior Authorization | |
|---|---|
| Aralast | Lemtrada |
| Berinert | Onpattro |
| Cerezyme | Prolastin |
| Cinqair | Ruconest |
| Cinryze | Soliris |
| Elelyso | Tysabri |
| Entyvio | Ultomiris |
| Exondys 51 | Uplizna |
| Givlaari | Viltepso |
| Glassia | VPRIV |
| Haegarda | Vyepti |
| Ilumya | Vyondys 53 |
| Kalbitor | Xolair |
| Kanuma | Zemaira |
If you have any questions, contact your account executive.
Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective January 1, 2022
Beginning January 1, 2022, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´ * plans with a three-tier pharmacy benefit. As part of this update, certain medications may:
- No longer be covered (exceptions may be granted)
- Switch tiers
- Have new quantity or dosing limits
- Require prior authorization and/or step therapy
*This doesn’t include Medex 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Medications No Longer Covered Starting January 1, 2022
After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.
| Medication Class | Medication Name | Covered Alternative |
|---|---|---|
| Anti-Parasite Treatment | Alinia | nitazoxanide |
| Glaucoma Treatment | Timoptic Ocudose | betaxolol levobunolol metipranolol timolol |
| H. Pylori Treatment | Omeclamox | lansoprazole/amoxicillin/clarithromycin pack Talicia |
| Multiple Sclerosis Treatment | Tecfidera* | dimethyl fumarate |
| Musculoskeletal Pain Treatment | Norgesic Forte orphenadrine/aspirin/caffeine |
orphenadrine |
| Nerve Pain Treatment | Lyrica | pregabalin* |
| Phenylketonuria Treatment | Kuvan | sapropterin |
| Short Acting Bronchodilators | ProAir HFA ProAir RespiClick |
albuterol sulfate HFA |
| Topical Corticosteroids | triamcinolone 0.05% ointment Trianex 0.05% ointment Tritocin 0.05% ointment |
triamcinolone 0.025% cream, lotion, ointment triamcinolone 0.1% cream, lotion, ointment triamcinolone 0.5% cream, ointment |
*This medication also has prior authorization and/or step therapy requirements.
Medications Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease.
| Medication Class | Medication Name | 2022 Tier | |||
|---|---|---|---|---|---|
| For members with a three-tier pharmacy benefit |
For members with a four-tier pharmacy benefit |
For members with a five-tier pharmacy benefit |
For members with a six-tier pharmacy benefit |
||
| Inflammatory Conditions | Avsola* | Tier 3b | Tier 4c | Tier 5d | Tier 6e |
| Cimzia* | Tier 3g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Orencia* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Orencia Clickjet* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Siliq* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Simponi* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Simponi Aria* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g | |
| Bowel Evacuants | Plenvu | Tier 3 g | Tier 4 g | Tier 3 g | Tier 4 g |
| Diabetes – SGLT2/DPP4 Inhibitor Combinations | Trijardy XR* | Tier 2c | Tier 3d | Tier 2c | Tier 3d |
| Inhaled Combination Agents | Breztri* Trelegy Ellipta* |
Tier 2 g | Tier 3 g | Tier 2 g | Tier 3 g |
| Methotrexate Autoinjectors | Otrexup* | Tier 3 g | Tier 4 g | Tier 5 g | Tier 6 g |
| Methotrexate Autoinjectors | Rasuvo* | Tier 3 g | Tier 4 g | Tier 3 g | Tier 4 g |
* This medication also has prior authorization and/or step therapy requirements.
- This medication was previously covered at Tier 1.
- This medication was previously covered at Tier 2.
- This medication was previously covered at Tier 3.
- This medication was previously covered at Tier 4.
- This medication was previously covered at Tier 5.
- This medication was previously covered at Tier 6.
- This medication was previously non-covered.
Medications with New Quality Care Dosing Limits
To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, some of the medications listed below now require Quality Care Dosing (QCD), while the QCD limit has changed for others.
| Medication Class | Medication Name | Quality Care Dosing Limit per prescription |
| Anti-Parasite Treatment | Alinia 500 mg tablets Nitazoxanide 500 mg tablets |
6 tablets |
| Alinia 100 mg/5 mL suspension | 180 mL | |
| Antineoplastic Medications | Jakafi 5 mg, 10 mg, 15 mg, 20 mg, 25 mg tablets | 60 |
| Pomalyst 1 mg, 2 mg, 3 mg, 4 mg capsules | 21 | |
| Cabometyx 20 mg, 40 mg, 60 mg tablets | 30 | |
| Tagrisso 40 mg, 80 mg tablets | 30 | |
| Verzenio 50 mg, 100 mg, 150 mg, 200 mg tablets | 60 | |
| Tardive Dyskinesia Treatment | Ingrezza 40 mg-80 mg initiation pack | 1 pack |
| Ingrezza 40 mg, 60 mg, 80 mg capsules | 30 |
Medical Policy Updates
Medical policies are evidence-based documents that Blue Cross develops to define the technologies, procedures, and treatments that are considered medically necessary, not medically necessary, and investigational. We use Pharmacy medical policies to describe how we cover certain medications. We’re updating the policies listed below. These changes include:
- Step therapy policy changes that apply to members newly prescribed the medications listed within the pharmacy medical policies. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
- Prior authorization for members newly prescribed Alunbrig.
| For this policy | Update |
| Anti-Migraine Policy (021) | Adding dihydroergotamine spray and Migranal spray to step 3 for acute migraine treatment. This will apply to members newly prescribed these medications. |
| Asthma and Chronic Obstructive Pulmonary Disease Medication Management (011) | Adding Trelegy Ellipta and Breztri as step 2 agents requiring the use of other covered products for Asthma/Chronic Obstructive Pulmonary Disease (COPD) to be used prior to approval. This will apply to members newly prescribed these medications. |
| Diabetes Step Therapy (041) | Moving Trijardy XR from step 3 to step 2 under the DPP4 and SGLT2 sections of the policy. Members with a claim history or an approved authorization don’t need to do anything, but these medications will now be covered at a lower-tier cost. New prescriptions for this medication will follow the step therapy policy. |
| Immune Modulating Drugs (004) | Adding Zeposia to non-preferred and requiring the use of two preferred agents prior to approval (when used to treat ulcerative colitis [UC]). This will apply to members newly prescribed these medications. |
| Injectable Methotrexate (Otrexup & Rasuvo) (840) |
New medical policy that requires the use of generic methotrexate before we’ll approve coverage of either Otrexup or Rasuvo. Applies to new prescriptions. |
| Multiple Sclerosis Step Therapy (839) | New medical policy that requires the use of dimethyl fumarate or glatiramer/Glatopa before we’ll cover other agents. Applies to new prescriptions. |
| Oncology Drugs (409) | Requiring prior authorization for Alunbrig. Applies to new prescriptions. |
Looking for More Information?
For more information about any of these medications, use the Medication Lookup tool at bluecrossma.org/medication.
Questions?
If you have any questions, please contact your account executive.
Health Plan Updates for 2022
Effective January 1, 2022, and upon renewal, we’re making changes to our health plans to ensure that we continue to meet the ongoing requirements of health care reform, while providing the high-quality, affordable coverage you and your employees expect from Blue Cross.
In 2022, we’ll offer:
- - BlueFit: the next generation, proactive health plan
- - Telehealth updates
- - Solutions that create value for our members
- Value care options
- 90-day retail medication dispensing
- $0 copay medications
- - Solutions supporting health and wellness
- Home fitness equipment reimbursement
- Optional Mind & Body Program
- - Solutions to address affordability
- New merged-market plan designs
- Plans designed for lower premiums
To see how these and our other updates will affect you, please review the relevant documents below:
Accounts with 50 or Fewer Enrolled
Accounts with 51–99 Enrolled
Accounts with 100 or More Enrolled
You can also use our Plan Comparison tool to find, compare, and download plan documents.
Questions?
If you have any questions, please contact your account executive.
Prior Authorization Change for Outpatient Services for EPO and PPO Plan Members
We originally notified you in November 2021 of this upcoming change, and then we updated you in December 2021 that we would be delaying the effective date due to a DOI bulletin. Today, April 15th, we are notifying you that this prior authorization change will take effect on June 1, 2022.
We're adding prior authorization requirements for certain outpatient services for EPO and PPO plan members, effective June 1, 2022. This requirement helps ensure members receiving safe, effective, and medically necessary services. Services include, but are not limited to:*
- Continuous glucose monitors
- Cosmetic procedures
- Nasal sprays or injections to treat depression
- Spine surgeries (except for Medicare PPO plan members)
- Stem cell transplants
Providers-both in network and out of network**-will need to request authorization for members receiving ongoing treatment, and for members who begin treatment on or after the effective date. We'll review requests against our necessity criteria.
If you have questions, please contact your account executive.
*Members should check their plan details for the full list of services, or call Member Service.
**This only applies to in-network providers of Medicare Advantage PPO plan members.
Expanded Coverage for Treatment of PANDA/PANS
As of January 1, 2022, Blue Cross Blue Shield of Massachusetts will expand coverage for the treatment of pediatric autoimmune neuropsychiatric disorders and pediatric acute-onset neuropsychiatric syndromes (PANDAS/PANS). This includes, but it is not limited to, intravenous immunoglobulin (IVIG) therapy.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndromes (PANS) can be triggered by a strep infection and occur suddenly in previously healthy children ages of 2-12. Symptoms can include obsessions and compulsions, extreme anxiety, trouble sleeping, difficulty with school work, bodily tics, and other ailments.
This treatment coverage applies to all members except Medicare Advantage and Federal Employee Program members.