We’re Expanding Our Behavioral Health Coverage for Children and Adolescents
Beginning July 1, 2019, Blue Cross Blue Shield of Massachusetts will cover the following services for members under 19 years old:
- In-Home Behavioral Health: Behavior Management Monitoring and Behavior Management Therapy
- In-Home Therapy: Therapeutic Clinical Intervention and Ongoing Therapeutic Training and Support
- Intensive Care Coordination
- Community Based Acute Treatment for Children and Adolescents (CBAT)
- Intensive Community Based Treatment for Children and Adolescents (ICBAT)
- Mobile Crisis Intervention
We already provide coverage for CBAT, ICBAT, and Mobile Crisis Intervention. We refer to CBAT and ICBAT as Acute Residential Treatment or Subacute Care.
Coverage for the new services will be effective upon renewal, beginning July 1, 2019, for insured accounts, administrative services only municipal accounts, and Blue Funding Solutions clients. These changes are in accordance with a bulletin released by the Massachusetts Division of Insurance on December 14, 2018, related to services for treating child/adolescent mental health disorders.
We’re taking the necessary steps to ensure that members are aware of these added benefits, including updating the Evidence of Coverage as of July 1, 2019, upon renewal.
Please be aware that coverage will be required for Family Support and Training as well as Therapeutic Mentoring, both of which will be effective July 1, 2020.
If you have any questions, please contact your account executive.
Expanded Coverage for Osteoporosis Screening in Women
As of June 1, 2019, we’re expanding our commercial plan coverage to provide osteoporosis screenings for women under 65 years old who are at increased risk. This reflects the recent change in the U.S. Preventive Services Task Force screening recommendations.
This expanded coverage will be available at $0 cost-share for fully insured and self-insured non-grandfathered plans, as well as grandfathered accounts that have adopted the Affordable Care Act’s Preventive Services benefits. Specific plan network requirements apply.
Flu Shot Program Changes
Our greatest priorities at Blue Cross Blue Shield of Massachusetts (“Blue Cross”) are to assist our members in accessing affordable, quality care, and to provide them with the best consumer experience possible. In support of these priorities, we regularly review our programs and services to ensure that they are still meeting the needs of our account partners and members.
With that in mind, we are announcing a change to our offering. Effective immediately, Blue Cross will no longer coordinate worksite influenza immunization (“flu clinic”) services. As the retail landscape changes—and flu shot accessibility increases—worksite flu clinics are no longer the most flexible, convenient option available to members.
Although we will no longer coordinate flu clinic services, we still strongly recommend that everyone gets their annual flu immunization. Virtually every retail pharmacy offers flu shots, and most members are within reasonable distance of a location that offers this service. Blue Cross members can also receive their flu vaccination from a wide variety of approved medical providers, including their own provider’s office or a limited service clinic (for example, CVS Minute Clinic). Members can find a list of available retail clinics on the MyBlue app. In most cases, there will be no cost for members to get their flu shot; however, we encourage members to verify their coverage with our Member Service team before receiving their vaccination.
If you have any questions about this change, please contact your Blue Cross Account Executive or Blue Cross Health Engagement Strategist.
Updates to Our Prior Authorization Requirements
Beginning July 1, 2019, our prior authorization requirements for the medications listed below are changing for members with our HMO, Access Blue, and Blue Choice® plans.
| Medication Name
|
Administration
|
|---|---|
|
Prior authorization is required for these medications when administered:
|
Medication Name
|
Administration
|
Prior authorization is required for these medications when administered:
|
This change doesn’t affect these medications when administered in inpatient care, surgical day care, urgent care centers, and emergency room settings.
Upcoming Changes to Our Pharmacy Program
Beginning July 1, 2019, we’re making changes to our list of covered medications for medical plans with pharmacy benefits, as well as Medex®' plans with a three-tier pharmacy benefit. We’ll notify impacted members by June 1, 2019. As part of these updates, certain medications may:
- No longer be covered
- Switch cost tiers
- Be excluded from pharmacy benefit coverage due to over-the-counter availability
- Require prior authorization
Certain Medication Will Become Non-Covered
After a careful review of its cost and covered alternatives, we’ve decided to remove the medication in the table below from our list of covered medications, effective July 1, 2019. A member’s doctor or prescriber may request a coverage exception if the medication is medically necessary. If the request is approved, the member will pay the highest-tier cost for the medication.
| Medication Class | Medication Name | Covered Alternative |
|---|---|---|
| Erythropoietins | Procrit* | Retacrit |
Medication Class
| Erythropoietins |
Medication Name
| Procrit* |
Covered Alternative
| Retacrit |
*Members currently filling prescriptions for Procrit may continue to do so under their existing prior authorization, but will see an increase in cost as the medication will move to the highest tier.
Medications That Are 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 higher tier, which means they may cost the member more.
|
Medication Class |
Medication Name |
2019 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 |
||
|
Topical Testosterone |
AndroGel |
Tier 3a |
Tier 4b |
Tier 3a |
Tier 4b |
|
Granulocyte Stimulant Factor |
Neulasta |
Tier 3a |
Tier 4b |
Tier 5c |
Tier 6d |
Medication Class
| Topical Testosterone |
| Granulocyte Stimulant Factor |
Medication Name
| AndroGel |
| Neulasta |
2019 Tier
For members with a three-tier pharmacy benefit
| Tier 3a |
| Tier 3a |
For members with a four-tier pharmacy benefit
| Tier 4b |
| Tier 4b |
For members with a five-tier pharmacy benefit
| Tier 3a |
| Tier 5c |
For members with a six-tier pharmacy benefit
| Tier 4b |
| Tier 6d |
a) This medication was previously covered at Tier 2.
b) This medication was previously covered at Tier 3.
c) This medication was previously covered at Tier 4.
d) This medication was previously covered at Tier 5.
Medications Excluded from Pharmacy Benefit Coverage
The following medications will be excluded from our pharmacy benefit coverage due to over-the-counter availability. 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.
| Medication Name |
| Differin 0.1% (All topical forms) |
| Adapalene 0.1% (All topical forms) |
| Proton pump inhibitors when included as part of a compounded medication* |
Medication Name
| Differin 0.1% (All topical forms) |
| Adapalene 0.1% (All topical forms) |
| Proton pump inhibitors when included as part of a compounded medication* |
*Members under the age of 18 will still be covered for these medications. However, prior authorization will be required for new prescriptions.
Medications Requiring Prior Authorization
For certain medications, the member’s doctor must first obtain approval before we cover it. The following medications will now require prior authorization:
- Axiron*
- AndroGel*
- Iressa*
- Gilotrif*
- Tarceva*
- Tagrisso*
- Neupogen
- Neulasta
- Haegarda
- Berinert
- Firazyr
- Kalbitor
- Ruconest
*Members currently filling prescriptions for these medications may continue to do so and won’t require prior authorization.
Questions?
If you have any questions, please contact your account executive.
New Orthodontic Payment Schedule
For all comprehensive orthodontic claims, with dates of service on or after January 1, 2019, payment will now be processed on a monthly schedule. This is a change from the previous arrangement, when these benefits were administered in two payments, six months apart.
What’s New?
Under the new payment schedule, an initial payment will be made for half of the member’s orthodontic benefit maximum for covered services, minus any member cost share (deductible, co-insurance). We’ll pay the remaining benefits in monthly installments, until the treatment plan is complete, or benefits are exhausted.
Claims in 2018
Our Dental Claims Team is reviewing comprehensive cases that are on active six-month payment schedules, for claims submitted prior to December 31, 2018. We’ll process these in full, up to the member’s benefit limit for claims received through December 31, 2018, ensuring a seamless transition to the new schedule in 2019.
We have informed dental care providers of this change, in a News Alert in October.
Expanded Coverage for Fluoride Supplements
Bright Futures, led by the American Academy of Pediatrics, has revised its recommendations for fluoride supplements to prevent dental cavities in children. As a result, effective January 1, 2019, as a one-day change, we're updating our commercial medical plan coverage to reflect these changes, ensuring compliance with Preventive Services under the Affordable Care Act (ACA).
Our new coverage expands the age range to six months through 16 years of age. This benefit will be available at a $0 cost share for fully insured and self-insured non-grandfathered plans, as well as grandfathered accounts that adopted the ACA's Preventive Services benefits. Coverage is subject to other health plan network requirements and provisions.
Upcoming Changes to Our Health Plans & Programs
Effective January 1, 2019, we’re making changes to some of our health plans and expanding the types of programs that qualify for our fitness and weight-loss reimbursement benefits. With these updates, we continue to meet regulatory requirements while providing you and your employees with access to high-quality, affordable health plans.
To see how these changes will affect you, please review the documents below for your account size.
Small Accounts (50 or fewer enrolled)
2019 Product and Benefit Updates
2019 HMO Product Coverage Options
2019 PPO Product Coverage Options
Mid-size (51-99 enrolled)
2019 Product and Benefit Updates
2019 HMO Product Coverage Options
2019 PPO Product Coverage Options
Large (100 or more enrolled)
2019 Product and Benefit Updates
2019 HMO Product Coverage Options
2019 PPO Product Coverage Options
You can also find, compare, and download plan documents with our Plan Comparison Tool.
If you have questions, please contact your account executive.
Upcoming Changes to Our Pharmacy Program
Beginning January 1, 2019, we're making changes to our list of covered medications for medical plans with pharmacy benefits, as well as Medex®' plans with a three-tier pharmacy benefit. As part of these updates, certain medications may:
- No longer be covered
- Switch tiers
- Have a new dosing limit
- Require prior authorization
- Change cost
Proton Pump Inhibitors No Longer a Covered Benefit in 2019
Effective January 1, 2019, proton pump inhibitors (medications commonly used to reduce stomach acid) will be excluded from our pharmacy benefit, except for members under the age of 18.
-
This benefit exclusion will apply to members 18 years of age and older who currently have pharmacy benefits.
- This benefit exclusion will not apply to members under the age of 18.
- This benefit exclusion will not apply to members being treated with combination prescription medications to treat Helicobacter pylori (H. pylori).
Exceptions will no longer be available for this class of medications, even if the member has a prescription or if we've covered it in the past.
Members should talk to their doctors about over-the-counter medication options that are available without a prescription.
This affects the following medications:
| Aciphex | Aciphex Sprinkle | Dexilant | esomeprazole magnesium | esomeprazole strontium |
| First-Lansoprazole | First-Omeprazole | lansoprazole | Nexium | omeprazole |
| omeprazole sodium bicarbonate | pantoprazole | Prevacid | Prilosec | Protonix |
| rabeprazole | Zegerid |
Medications No Longer Covered in 2019
After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the table below from our covered medications list. However, a doctor may request an exception if these medications are medically necessary. If the exception is approved, the member will pay the highest-tier cost.
| Medication Class | Non-Covered Medication or Supply | Covered Alternative |
| Anticoagulants (medications to treat and prevent blood clots) | Pradaxa* | Eliquis, Xarelto, warfarin |
| Colchicine Products (medications to treat gout) | Single-source colchicine products (colchicine products that resemble generic versions in name only) | Colcrys, Mitigare |
| Dopamine Agonists (treatment for Parkinson's disease) | Mirapex | ropinirole, pramipexole |
| Glucagon-Like Peptide 1 Agonists (injectable medications to treat diabetes) | Victoza | Byetta, Bydureon, Trulicity |
| Granulocyte Stimulants (white blood cell replacement agents used during chemotherapy) | Neupogen**†† | Zarxio††, Granix†† |
| Ophthalmic Anti-Inflammatory (short-term medications to treat inflammation in the eye) | FML S.O.P., FML Liquifilm, Pred Mild, Maxidex, Flarex | Lotemax, generic ophthalmic steroid medications |
*Members currently using Pradaxa will be given an exception to continue their coverage until December 31, 2019, but they'll pay the highest-tier cost since the medication will no longer be covered.
**Members currently using Neupogen will be given an exception to continue their coverage until May 31, 2019, but they'll pay the highest-tier cost since the medication will no longer be covered.
††This medication must be filled at an in-network retail specialty pharmacy.
Medications That Are Switching Tiers
When the cost of a medication changes, we may move the medication to a different tier. Depending on the tier change, what members pay for the following medications may increase or decrease:
| Medication Class | Medication Name | 2019 Tier (for members with a three-tier pharmacy benefit) | 2019 Tier (for members with a four-tier pharmacy benefit) | 2019 Tier (for members with a five-tier pharmacy benefit) | 2019 Tier (for members with a six-tier pharmacy benefit) |
| These medications are moving to a higher tier, which means they may cost more for members. | |||||
| Infliximab Products (immunosuppressive medications to treat psoriasis, rheumatoid arthritis, Crohn's disease, etc.) | Remicade†† Renflexis†† | Tier 3a | Tier 4b | Tier 5c | Tier 6d |
| Multiple Sclerosis: Oral Agents | Aubagio†† | Tier 3a | Tier 4b | Tier 5c | Tier 6d |
| These medications are moving to a lower tier, which means they may cost less for members. | |||||
| DPP4/SGLT2 Inhibitor Combinations (oral medications to treat diabetes) | Glyxambi | Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Insulins - Basal | Basaglar | Tier 2e | Tier 3e | Tier 2e | Tier 3e |
| Multiple Sclerosis: Beta-Interferons | Plegridy†† | Tier 2e | Tier 3e | Tier 4e | Tier 5e |
| Novel Psychotropics: Long Acting (medications to treat psychological disorders) | Abilify- Maintena | Tier 2e | Tier 3e | Tier 2e | Tier 3e |
a) This medication was previously covered at Tier 2.
b) This medication was previously covered at Tier 3.
c) This medication was previously covered at Tier 4.
d) This medication was previously covered at Tier 5.
e) This medication wasn't previously covered.
††This medication must be filled at an in-network retail specialty pharmacy.
Medications with New Quality Care Dosing Limit
To make sure that the quantity and dose of a medication meets the Food and Drug Administration, manufacturer, and clinical recommendations, we're reducing Quality Care Dosing Limits for the following medications:
| Medication Name | Quality Care Dosing Limit |
| Morphabond ER 60mg | 60 per prescription |
| Morphabond ER 100mg | 30 per prescription |
Medications Requiring Prior Authorization (for new prescriptions only)
A member's doctor is required to obtain prior authorization before we'll cover certain medications. The following medications will require prior authorization for new prescriptions in 2019. Members currently taking the medications will be given an exception and won't need prior authorization:
- Breo Ellipta
Higher Costs for Medications with Supplies Longer Than 30 Days
The cost for the medications listed below is increasing. These medications are usually dispensed in a supply longer than 30 days. We've typically only charged members a 30-day copayment for these medications. Beginning January 1, 2019, members will have to pay an adjusted copayment based on the supply length.†
For example: if your copayment is $25 for a 30-day supply, you'll pay $75 for a 90-day supply.
| fluphenazine decanoate | Eligard†† | leuprolide acetate†† | Lupron Depot†† |
| Lupron Depot Pediatric†† | Zoladex†† | haldol decanoate | haloperidol decanoate |
† This change only applies to members with a prescription plan that uses a copayment.
††This medication must be filled at an in-network retail specialty pharmacy.
How Members Can Save Money for Long-Term Prescriptions
Members may be able to save money for long-term medications, also known as maintenance medications, when they order prescriptions through our mail order pharmacy. Members can visit MyBlue to learn more, or get started online by visiting Express Scripts®'', an independent company that manages member pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts. Members can also call them directly at 1-800-892-5119.
Questions?
If you have any questions, please contact your Account Executive.
Reminder: Proton Pump Inhibitors To Be Excluded from Pharmacy Coverage Starting January 2019
Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medications, except for members under the age of 18 and those taking combination medications to treat H. pylori. This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We're making this change because several products in this class are available over the counter.
Opioid Overdose Reversal Drugs Available at No Cost for ASC Members
Beginning January 1, 2019, Blue Cross Blue Shield of Massachusetts will make Narcan®' and naloxone, two common drugs for treating a narcotic overdose, available at no cost to members* under our pharmacy benefit for all ASC accounts upon renewal.
This change is part of our ongoing strategy to combat misuse and overuse of opioids. By making Narcan and naloxone available to our members at no cost, we hope to provide easier access to these potentially life-saving medications.
If you have questions or would like to opt out of this change, please contact your Account Executive.
*Accounts will still be responsible for the cost of the drug; For ASC plans with an HSA, members will have full coverage for the cost of the drug once their deductible has been met.
Member ID Card Changes
We're making several important changes to the language on the back of our standard Member ID cards:
- Behavioral Health and Substance Abuse will be updated to Behavioral Health and Substance Use Disorder. This better aligns with updated terminology in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and destigmatizes the language used to describe the opioid crisis and those impacted by it.
- Blue Care Line will be updated to 24/7 Nurse Care Line.
The phone numbers will not change. These updates will apply to all cards issued to new members on or after the effective date of September 1, 2018. Member ID cards currently in circulation won't be impacted.
Accounts with a customized card back will be reviewed upon renewal and may choose to opt in or out to these updates. If you have any questions, please contact your Account Executive.
New Changes to Our Specialty Pharmacy Network
Effective September 1, 2018, we'll be making the following changes to our specialty pharmacy network:
- BriovaRx® is joining.
- AllianceRx Walgreens Prime is leaving, but will remain within our fertility network.
- AllCare Plus Pharmacy and Onco360 will also be leaving.
By August 1, we'll contact members who fill their prescriptions at the pharmacies that are leaving our network to help them transition to an in-network pharmacy.
Specialty pharmacies provide medications that are used to treat certain complex health conditions. You can view our Specialty Medications here.
If you have any questions, please contact your account executive.
Upcoming Changes to Our Specialty Pharmacy Network
Effective September 1, 2018, we're making changes to our specialty pharmacy network. As part of these changes, AllCare Plus Specialty Pharmacy and Onco360 will be leaving the network.
We'll contact members who fill their prescriptions for specialty medications at AllCare Plus and Onco360 by August 1, 2018 to help them transition to an in-network specialty pharmacy.
Specialty pharmacies provide medications that are used to treat certain complex health conditions.
If you have any questions, please contact your account executive.
Retraction: Update Regarding Changes to Continuous Glucose Monitor Sensor Coverage
In our March IAI, we stated that beginning July 1, 2018, we would provide coverage for continuous glucose monitor (CGM) sensors under the Durable Medical Equipment (DME) benefit. We have decided that coverage for CGM sensors will remain unchanged.
If you have questions, please contact your sales executive.
Changes to Continuous Glucose Monitor Sensor Coverage
Beginning July 1, 2018, we'll provide coverage for continuous glucose monitors (CGMs) sensors under the Durable Medical Equipment (DME) benefit. Previously, CGMs sensors were covered under pharmacy benefits. The move to DME was made, in part, to ease confusion among members as to coverage requirements for the CGM sensors.
If you don't have pharmacy coverage but already provide coverage for the CGM sensors under DME benefits, there's no change to your plan. We'll notify affected members of the change by letter prior to June 1, 2018.
If you have questions, please contact your account or sales executive.
New Prior Authorization Requirements for HMO, Access Blue, and Blue Choice® Plans
Beginning July 1, 2018, prior authorization is required for the medications listed below when administered:
- In a doctor's office
- By home health care providers
- By home infusion therapy providers
- In outpatient hospital and dialysis settings
This change doesn't affect these medications when used in inpatient, surgical day care, urgent care centers, and ER settings. We encourage your employees to discuss this change with their health care provider.
Medications that require prior authorization:
- Cosentyx
- Hemlibra
- Inflectra
- Kevzara
- Rebinyn
- Renflexis
- Siliq
- Taltz
- Tremfy
- Tretten
Coming in July 2018: Changes to Our Pharmacy Program
Beginning July 1, 2018, we're making changes to our covered medications list for medical plans with pharmacy benefits, and Medex®' plans with the three-tier pharmacy benefit. These changes affect:
- Medications switching tiers
- Medications that are no longer covered
- Medication dosing limits
Medications Switching Tiers
When the cost of a medication changes, we move the medication to a different tier. Depending on the tier change, member payments for the following medications may increase or decrease:
| Medication Class | Medication Name | New Tier as of July 1, 2018 (applies to 3-tier or 5-tier pharmacy benefits) | New Tier as of July 1, 2018 (applies to 4-tier or 6-tier pharmacy benefits) |
| Dermatological | Doxepin cream | Tier 21 | Tier 32 |
| Inhaled combination for chronic obstructive pulmonary disease | Anoro Ellipta | Tier 21 | Tier 32 |
1. This medication was previously covered at Tier 1.
2. This medication was previously covered at Tier 2.
Medications No Longer Covered
After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list. However, when these medications are medically necessary, a member's doctor or prescriber may request a coverage exception.
| Medication Class | Non-Covered Medication or Supply | Covered Alternative |
| Multi-Source Brands | Provigil Lidoderm Patch | Modafinil Lidocaine Patch |
Medications with New Dosing Limits
To ensure the quantity and dose of a medication meets the Food & Drug Administration's regulations, manufacturer's guidelines, and clinical recommendations, we're adding a Quality Care Dosing Limit to the following medications:
| For This Medication | The Quality Care Dosing Limit Per Prescription | Additional information |
| Naloxone Carpuject (vial and syringes | Two per 30 days | We're also making this available at no cost beginning 6/1/18 for Fully Insured Accounts, so our members have access to this medication. If your employees are on a Saver plan, the deductible will still apply first. |
| Narcan nasal spray | Two per 30 days | |
| Evzio | Two per 30 days | N/A |
Proton Pump Inhibitors Will Be Excluded from Pharmacy Coverage In 2019
Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. Pylori.
This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We'll notify impacted members beginning in November 2018 prior to the change.
Health Plans for Account Sizes
Beginning January 1, 2018, we'll implement changes to our health plans. These changes will ensure that our plans continue to meet the ongoing requirements of the Affordable Care Act (ACA), while continuing to provide high-quality, affordable health coverage options. We're also excited to soon offer new plan options.
To see how these changes will affect you, please review the documents below for your account size.
Small Accounts (50 or fewer enrolled)
2018 Product and Benefit Updates
2018 HMO Product Coverage Options
2018 PPO Product Coverage Options
Mid-size (51-99 enrolled)
2018 Product and Benefit Updates
2018 HMO Product Coverage Options
2018 PPO Product Coverage Options
Large (100 or more enrolled)
2018 Product and Benefit Updates
2018 HMO Product Coverage Options
2018 PPO Product Coverage Options
You can also find, compare, and download plan documents with our Plan Comparison Tool.
If you have questions, please contact your account executive.
Coming in 2018: Updates to Our Covered Medications List
Beginning January 1, 2018, we're making changes to our covered medications list for commercial medical plans with pharmacy benefits, and Medex®' plans with the three-tier pharmacy benefit.
As part of these updates, certain medications will:
- No longer be covered
- Have a new dosing limit
Medications No Longer Covered
After reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list. However, when medically necessary, a member's doctor or prescriber may request a coverage exception; if approved, the medication will process at the highest tier.
| Medication Class | Non-Covered Medication or Supply | Covered Alternative |
| Biguanides for Diabetes | Generic Metformin Film Coated ER version of Fortamet |
Metformin 500mg, 850mg, 1000mg(Generic version of Glucophage) Metformin ER 500mg, 750mg (Generic version of Glucophage XR) |
| Estrogen and Estrogen Modifiers | Femring | Estrace Estring Premarin |
| Glucagon-Like Peptide-1 Agents | Tanzeum* | Bydureon Byetta Trulicity |
| Novel Psychotropics | Abilify Geodon Seroquel Zyprexa Zyprexa Zidis | aripiprazole ziprasidone quetiapine olanzapine olanzapine ODT |
*Existing users may continue to fill this medication but will experience a tier change.
Medication with New Quality Care Dosing Limit
To make sure that the quantity and dose of a medication meets the Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing Limit to the following medication:
| Medication Name | Quality Care Dosing Limit |
| Humira Pediatric Crohn's Starter Pack | 1 Pack (2 Syringes) |
*This impacts new starts only. There will be no impacted member communications
Proton Pump Inhibitors Will Be Excluded from Pharmacy Coverage
Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. Pylori.
This change applies to all commercial plans, group Medex plans with the three-tier pharmacy benefit, and Managed Blue for Seniors plans. We will notify impacted members beginning in November 2018 prior to the change.
AllCare Plus Specialty Pharmacy Is Joining Our Network
This summer your employees will have another retail specialty pharmacy option where they fill their prescriptions for specialty medications. Starting July 1, 2017, AllCare Plus Pharmacy is joining our retail specialty pharmacy network. You can view our Specialty Medications List here. We're updating this list on July 1 to include the medications AllCare Plus fills.
You can reach AllCare Plus at 1-855-880-1091 or allcarepluspharmacy.com.
Proton Pump Inhibitors Will Be Excluded from Pharmacy Coverage
Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. pylori. This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We're making this change because several products in this class are available over the counter.
Changes to Our Pharmacy Program
Beginning September 1, 2017, we're making changes to our covered medications list that will affect:
- Medications switching tiers
- Medications that are no longer covered
- One medication moving to benefit exclusion (also impacts Managed Blue for Seniors)
Plans affected by the changes:
- Commercial medical plans with pharmacy benefits
- Medex®' plans with the three-tier pharmacy benefit
Medications Changing Tier Status
When the cost of a medication changes, we move the medication to a different tier. Depending on the tier change, members may be required to pay more or less for the following medications:
| Medication Class | Medication Name | Covered Tier Level as of September 1, 2017 under a 3 Tier Formulary | Covered Tier Level as of September 1, 2017 under a 4 Tier Formulary |
| Proton Pump Inhibitors (PPI) | Esomeprazole Lansoprazole Omeprazole Omeprazole/BiCarb Pantoprazole Rabeprazole Prevacid SoluTab | Tier 3 | Tier 4 |
| Syringes | Terumo Thinpro Ulticare | Tier 2 | Tier 3 |
Note: Members using combination prescription medications to treat H. pylori will continue to pay their current cost.
Medications No Longer Covered
After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list for the plans referenced above. However, when these medications are medically necessary, a member's doctor or prescriber may request a coverage exception.
| Medication Class | Non-Covered Medication or Supply |
| Angiotensin II Receptor Blockers (for high blood pressure) | Azor, Benicar, Benicar HCT, and Tribenzor |
| Antipsychotic Medications | Seroquel XR |
| Asthma/Allergy Treatment | Singulair |
| Cholesterol-Lowering Medications | Zetia |
| Colonoscopy Preparation/ Laxatives | Osmoprep* |
| Dermatological Treatments | Alcortin-A, Anusol HC Suppository, Lidocaine-HC 2%-2.5% Kit, Relador Pak, Relador Pak Plus, Salicylic Acid 6% Lotion Kit |
*Since Osmoprep is a one-time use medication, we will not issue member letters.
Medication Excluded from Pharmacy Coverage
The following medication will be excluded from our pharmacy coverage because it's cosmetic. This change will apply to all commercial plans, group Medex®' plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exception will not be accepted for this medication.
| Medication Name |
| Avenova Lid-Lash Spray |
New Prior Authorization Requirements for HMO, Access Blue, and Blue Choice Plans
Beginning September 1, 2017, prior authorization is required for the medications listed below when administered:
- In doctor offices
- By home health care providers
- By home infusion therapy providers
- In outpatient hospital and dialysis settings
This change doesn't affect these medications when used in inpatient, surgical day care, urgent care centers, and ER settings. We encourage your employees to discuss this change with their health care provider.
Medications that require prior authorization:
- Egrifta
- Exondys-51
- Gel-Syn
- Ixinity
- Kanuma
- Kovaltry
- Lemtrada
- NovoEight
- Obizur
- Spinraza
- Zomacton
Hospital Network Update for Blue Options v.4 Plans
We're updating the Blue Options v.4 hospital network in response to the merger of Baystate Mary Lane Hospital and Baystate Wing Hospital on September 10, 2016. As you may know, at that time Baystate Mary Lane Hospital closed its inpatient unit but remained open as an outpatient location of Baystate Wing Hospital.
To provide geographic access for our Hampshire County members, we've designated Cooley Dickinson Hospital as a Select tier hospital. Effective September 10, 2016, Cooley Dickinson Hospital has the same modified member cost share as other geo-access hospitals for members with our Blue Options v.4 plans. This designation will result in lower out-of-pocket costs for members when they receive services at Cooley Dickinson Hospital.
This hospital update has no impact on Blue Options v.5 plans. By January 1, 2017, all members in Blue Options v.4 will have transitioned to Blue Options v.5.
St. Elizabeth’s Medical Center remains in the Standard Tier
In August 2016, we made an error when reviewing St. Elizabeth’s Medical Center’s tier status for our HMO and PPO Blue Options tiered network products. St. Elizabeth’s successfully fulfilled the quality requirements for our Tiered Network, which led to us announcing that this facility would transfer from our Standard Benefits Tier to the Enhanced Benefits Tier.
After further review, we realized that this transfer was made in error, and have decided to keep St. Elizabeth’s in the Standard Benefits Tier as a result of its costs remaining in the middle tier.
We apologize for any inconvenience this has caused you, and encourage you to contact your account executive if you have any questions or concerns.
Coming in 2017: Updates to Our Pharmacy Formulary Program
On January 1, 2017, we will be updating our formulary program. We have already advised prescribers of the upcoming changes. If your employees are affected by these changes, they will receive notification on or before December 1, 2016.
As part of the pharmacy updates, certain medications will be removed from our formulary, the coverage tier on some medications will change, and dosing limits will be applied to certain medications. In addition, all inhaled nasal steroids used to treat allergies, in the therapeutic class, will be excluded from our pharmacy benefit coverage. These changes are specified below.
Two Types of Plans Will Be Affected:
- Commercial medical plans with pharmacy benefits
- Medex®' plans with the three-tier pharmacy benefit
Medications That Will No Longer Be Covered
After carefully reviewing each drug’s cost and covered alternatives, we have removed the medications in the chart below from our formulary for the above-referenced plan types. However, when medically necessary, a member’s doctor or prescriber may request an exception to have these medications covered.
| Drug Class | Non-Covered Medication or Supply |
| Immune Modulating Drug* | Cimzia, Entyvio, Orencia, Simponi, Simponi Aria |
| Inflammatory Bowel Agents | Asacol, Delzicol, Mesalamine HD |
| Hepatits C* | Sovaldi |
| Acne Combinations with Antibiotics | Duac gel kit, Benzaclin gel and pump |
| Vitamins-Single Ingredient | Nascobal |
| Angiotensin II Receptor Antagonists and Combinations | Avapro, Avalide, Diovan, Diovan HCT, Exforge, Exforge HCT |
| HMG CoA Reductase Inhibitors (cholesterol) | Crestor |
| Medications included as part of Compounded Medications | Duloxetine capsules, irenka capsules, saltstable LO cream, salstable LS cream |
| Oral Contraceptives | Minastrin FE Chewable |
*Members currently taking these medications will be allowed to continue to take these medications. Members taking Orencia and/or Sovaldi will be affected by a tier change for these drugs to the highest tier.
Medications Changing Tier Status
When we determine that a medication’s clinical and financial value changes in comparison to alternative medications in its class, we change the medication’s tier. Depending on the tier change, members may be required to pay more or less for these medications. The medications in the table below will change tiers:
The medications in the table below will change tier levels:
| Drug Class | Medication Name | Covered Tier Level as of January 1, 2017 under a 3 Tier Formulary | Covered Tier Level as of January 1, 2017 under a 4 Tier Formulary |
| Topical Retinoic Acids | tretinoin, tretinoin microsphere, adapalene | Tier 2 | Tier 2 (no change from 2016) |
| Syringes | Ulticare, GNP Ultra | Tier 2 | Tier 2 |
| Non Covered Generic Medications with approved Formulary Exception | Avita, DermaWerx Surgical Plus Pak, Eletone, HPR Plus, Lidocaine/Hydrocortisone Gel and Cream kits, Salicylic Acid/Ceramide 6% kit | Tier 3 | Tier 4 |
Medication with New Quality Care Dosing Limit
To make sure that the quantity and dose of a medication meets the Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing Limit to the following medications:
| Medication Name | Quality Care Dosing Limit |
| Diclofenac 1.5% solution | 150ml |
| Diclofenac 1% gel | 500GM |
| Diclofenac 3% gel | 100GM |
| Lidocaine 5% 35GM ointment | 35GM (1 tube) |
| Lidocaine 5% 50GM ointment | 50GM (1 tube) |
| Voltaren 1% gel | 500GM |
| Breo-Ellipta 200/25mcg 28 pack | 28 blisters |
| Breo-Ellipta 100/25mcg 28 pack | 28 blisters |
| Climara-Pro patch | 4 patches |
| Nucynta 50, 100, 150, 200mg | 60 tabs |
| Pennsaid 2% pump 112 gm | 1 bottle |
Medication Class That Will Be a Benefit Exclusion
Effective January 1, 2017, all inhaled nasal steroids used to treat allergies, in the therapeutic class, will be excluded from our pharmacy benefit coverage. Formulary exceptions, including those previously approved, will no longer be available for this class of medications. This change applies to all non-grandfathered commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for Seniors plans. We are making this change due to the over-the-counter availability of several products in this class, which can be purchased without a prescription.
If you have any questions about these changes, please contact your account executive.
Changes to Out-of-Network Provider Claims Reimbursement
To reduce exposure to high, out-of-network provider charges, Blue Cross Blue Shield of Massachusetts is enhancing the standard out-of-network provider reimbursement approach for fully insured PPO plans. For out-of-network provider claims processed on and after January 1, 2018, Blue Cross will calculate most out-of-network claim payments based on 150 percent of the Medicare fee schedule. When no Medicare fee is available, Blue Cross will calculate the claim payment based on an amount determined by using current, publicly–available data reflecting fees typically reimbursed for the service, adjusted for geographic variations. Currently, the standard approach relies on the Blue Cross indemnity fee schedule to price these out-of-network claims. As a result of this change, use of the Blue Cross indemnity fee schedule as the standard approach for out-of-network reimbursement purposes will be eliminated.
These changes will be incorporated into PPO subscriber certificates upon the 2017 renewal.
Fully insured PPO accounts for which out-of-network claims currently are paid using a non-standard approach, will be migrated to the new standard out-of-network reimbursement approach upon their 2018 renewal, unless at that time Blue Cross approves use of provider charges as a non-standard benefit.
Out-of-network reimbursement changes also are being developed for ASC PPO plans and will be addressed in a future communication.
For more information, please contact your account executive.
Beginning January 1, 2017, we’ll implement changes to our health plans. These changes will ensure that our plans continue to meet the ongoing requirements of the Affordable Care Act (ACA), while continuing to provide high-quality, affordable health coverage options. We're also excited to soon offer new plan options.
To see how these changes will affect you, please review the documents below for your account size.
Small Accounts (50 or fewer enrolled)
2017 Product and Benefit Updates
2017 HMO Blue New England Product Coverage Options
2017 PPO Product Coverage Options
Mid-size (51-99 enrolled)
2017 Product and Benefit Updates
2017 HMO Blue New England Product Coverage Options
2017 PPO Product Coverage Options
Large (100 or more enrolled)
2017 Product and Benefit Updates
You can also find, compare, and download plan documents with our Plan Comparison Tool.
If you have questions, please contact your account executive.
Provider Tier Update for Blue Options v. 5 and Hospital Choice Cost Sharing
As a result of favorable improvements in the following hospitals’ cost or quality performance, we are updating their tier in our Blue Options v.5 benefit designs and Hospital Choice Cost Sharing benefit designs. This one-day change is effective for all plans and accounts on January 1, 2017. With this update, members will have lower out-of-pocket costs when receiving services at these hospitals.
Blue Options v.5:
| Hospital | Previous Blue Options Tier | New Blue Options Tier | Reason for Tier Improvement |
| Sturdy Memorial Hospital | Basic Benefits Tier | Standard Benefits Tier | Met moderate cost benchmark |
| Nashoba Valley Medical Center | Standard Benefits Tier | Enhanced Benefits Tier | Met quality benchmark |
Hospital Choice Cost Sharing:
| Hospital | Previous HCCS Cost Share | New HCCS Cost Share | Reason for Tier Improvement |
| Sturdy Memorial Hospital | Higher Cost Share | Lowest Cost Share | Met moderate cost benchmark |
If you have any questions, Please contact your account executive.
PPO Member Attribution and Billing
We're committed to providing your employees access to the best health care possible. That's what led us to expand our industry-leading Alternative Quality Contract (AQC) payment model to our Preferred Provider Organization (PPO) members.
With this expansion, we're making efforts to improve the cost and quality of care for our members. This requires us to attribute your employees who are on a Blue Cross PPO plan to a health care provider who will act as a primary care provider (PCP) and be responsible for coordinating the patient's total care.
In the future, and continually as new health care provider groups are added or attribution changes, letters will be sent to notify your employees that they have been attributed to a health care provider in the network. Members outside Massachusetts would be attributed to the local Blue Plans' contracted and qualified health care providers and in-state members will receive the communication from us.
In March, our mailing will include employees attributed to one of these five physician groups:
- Lahey Health
- Lowell General Hospital
- Mount Auburn Cambridge Independent Practice Association and Mount Auburn Hospital
- Partners Healthcare
- Steward Health
The letter will inform your employees that we will begin sharing health information such as prescriptions and health care provider visits, with the attributed health care provider who will coordinate their care.
For self-insured accounts, your monthly invoices will reflect a per member per month cost for each employee attributed to an in-state or out-of-state provider who is covered by a value-based contract. The sum of in-state and out-of-state costs will be identified under the heading "Member Based Charge."
How Attribution Works
We determine member attribution by using claims data that includes identifying a consistent pattern of visits and prescriptions with a particular health care provider. If a member wants to make a change to a new or different PCP, they can do so easily by calling Member Service.
Attribution does not affect PPO coverage, and PPO members won't need a referral to see other health care providers, including specialists.
Our model provides a quality care advantage that has proven to reduce medical spending and improve health outcomes, which helps to strengthen your workforce and make health care more affordable for you. It's how we're driving health care to work better and leading the way to lower costs and better health.
If you have questions, please contact your account executive.