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What's New

Plan Updates

2021 Plan Updates

Upcoming Changes to Opioid Coverage

We’re making several changes to our coverage of opioids, a class of medication that’s sometimes prescribed by doctors and providers to treat pain. Effective April 1, 2021, we’ll cover Xtampza ER. With this change, we’ll no longer cover OxyContin and Oxycodone ER, the authorized generic, as of July 1, 2021. We’ll work with prescribers to transition members to Xtampza ER, the covered alternative, when clinically appropriate. Prescribers will need to request prior authorization for Xtampza ER.

If a member needs to continue taking OxyContin or Oxycodone ER, their prescriber may request an exception if the medication is medically necessary. If the exception is approved, the member will pay the highest-tier cost.

Prescribers without Prior Authorization Must Request It before July 1, 2021

To support the safe and appropriate use of opioids, we’re expanding our Pain Management Policy. With the expansion, prescribers who don’t have an approved authorization for coverage of a member’s opioid medication must request authorization for that member’s medication before July 1, 2021. We’ll then review the request to determine if the medication is medically necessary. Prescribers who’ve already received prior authorization for a member’s opioid medication don’t need to request it again until it expires. Oncologists, palliative care providers, and pain management specialists in the Blue Cross Blue Shield of Massachusetts network are exempt from this prior authorization requirement. We’ll notify affected prescribers and members of this change.

If you have any questions, please contact your account executive.


Additional Behavioral Health Coverage for Children and Adolescents

Beginning January 1, 2021, and effective upon account renewal, Blue Cross Blue Shield of Massachusetts will cover the following behavioral health services for members under 19 years old:

  • Family Support and Training (FS&T): medically necessary education for a child’s parent or caregiver, given in the home to help resolve the child’s emotional or behavioral health needs and identify additional services and support in their community.
  • Therapeutic Mentoring (TM): medically necessary services for a child, given in the home to support the child’s social functioning, especially after an emotional or behavioral health disorder diagnosis. TM services may include supporting, coaching, and training the child in age-appropriate behaviors, interpersonal communication, problem-solving, conflict resolution, and relating appropriately to other children, adolescents, and adults.

These services are in addition to the Intensive Community-Based Treatment (ICBT) for children and adolescent behavioral health services we’ve covered since July 1, 2019, effective upon renewal for fully insured accounts, administrative only municipal accounts, and Blue Funding Solutions; and January 1, 2020, effective upon renewal for self-insured accounts:

  • In-Home Behavioral Services: 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 (MCI)

ICBT offers a family- and home-based treatment approach, in which clinical services are provided in the child’s or adolescent’s home and community, with the intent of keeping the patient in their home and community. CBAT and ICBAT are forms of acute residential treatment or sub-acute care. Wrap-around services are community-based interventions developed by a multidisciplinary team and personalized to focus on the strengths and needs of the patient and family. ICBT services delivered outside Massachusetts may vary based on state legislation.

Coverage for the new services will be effective upon renewal for fully insured accounts, self-insured accounts, administrative only municipal accounts, and Blue Funding Solutions. We’re taking the necessary steps to ensure that members are aware of these added benefits, including updating the Evidence of Coverage, upon renewal.

If you have questions, contact your account executive.


Updates to the Blue Cross Blue Shield of Massachusetts Formulary Changes, Effective January 1, 2021

We’ve updated the Blue Cross Blue Shield of Massachusetts formulary changes going into effect January 1, 2021.


Medications No Longer Covered Starting January 1, 2021

The non-covered and covered alternatives for high-triglyceride treatments and muscle relaxants are changing. Chlorzoxazone 250 mg will no longer be a covered alternative to specific Lorzone medications and will remain non-covered. The correct medications and covered alternatives are listed below:

Medication Class Medication Name Covered Alternatives
High-triglyceride treatments fenofibrate 50 mg
fenofibrate 150 mg
fenofibrate 40 mg
fenofibrate 43 mg
fenofibrate 48 mg
fenofibrate 54 mg
fenofibrate 67 mg
fenofibrate 120 mg
fenofibrate 130 mg
fenofibrate 134 mg
fenofibrate 145 mg
fenofibrate 160 mg
fenofibrate 200 mg
Muscle relaxants cyclobenzaprine 7.5 mg cyclobenzaprine 5 mg
cyclobenzaprine 10 mg
Lorzone 375 mg
Lorzone 750 mg
chlorzoxazone 500 mg


Medications Switching Tiers

Medications in the high-triglyceride treatment class listed below will move to a higher cost tier, so members’ out-of-pocket costs for these medications may increase.

Medication Class Medication Name 2021 Tier for members with a three-tier pharmacy benefit 2021 Tier for members with a four-tier pharmacy benefit 2021 Tier for members with a five-tier pharmacy benefit 2021 Tier for members with a six-tier pharmacy benefit
High-triglyceride treatments fenofibrate 40 mg, 43 mg, 120 mg, and 130 mg Tier 2a Tier 3b Tier 2a Tier 3b

a. This medication was previously covered at Tier 1.
b. This medication was previously covered at Tier 2.


Medications with New Quality Care Dosing Limits

Quality Care Dosing helps us ensure that the quantity and dose of certain prescription medications meet the Food and Drug Administration, manufacturer, and clinical recommendations. Two additional medications will have Quality Care Dosing limits:

Medication Class Medication Name Quality Care Dosing Limit
per Prescription
Immunomodulators Humira CF Pen 40 mg/0.4 ml 2 pens
Kineret 100 mg/0.67 ml syringe 30 syringes

If you have any questions, please contact your account executive.


Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective January 1, 2021

Beginning January 1, 2021, 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
  • Have new quantity or dosing limits
  • Require prior authorization and/or step therapy

*This doesn’t include Medex 2 plans with Blue MedicareRxTM (PDP) prescription drug coverage.

Medications No Longer Covered Starting January 1, 2021

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 these medications are medically necessary. If the exception is approved, the member will pay the highest-tier cost.

Medication Class Medication Name Covered Alternative
Antihistamines Ryvent 6 mg carbinoxamine 4 mg
Antihypertensive Agents Lotrel amlodipine/benazepril
Tarka trandolapril/verapamil
Biologic Agents Cosentyx Enbrel
Humira
Otezla
Skyrizi
Stelara
Taltz
Tremfya
Xeljanz
Xeljanz XR
Buprenorphine/Naloxone
Sublingual Products
Bunavail
Suboxone
Zubsolv
buprenorphine/naxolone SL film buprenorphine/naxolone SL tablets
Colchicine Products Colcrys colchicine tablets
Mitigare
Contraceptives NuvaRing etonogestrel/ethinyl estradiol vaginal ring1
Cough/Cold Agents benzonatate 150 mg benzonatate 100 mg
benzonatate 200 mg
Glaucoma Treatments Alphagan P
Azopt
Betimol
Betoptic S
Timoptic
betaxolol
brimonidine
dorzolamide
dorzolamide/timolol
timolol
High Triglyceride Treatments fenofibrate 50 mg
fenofibrate 150 mg
fenofibrate 40 mg
fenofibrate 43 mg
fenofibrate 48 mg
fenofibrate 54 mg
fenofibrate 67 mg
fenofibrate 120 mg
fenofibrate 130 mg
fenofibrate 134 mg
fenofibrate 145 mg
fenofibrate 160 mg
fenofibrate 200 mg
Infertility Treatments Chorionic Gonadotropin Pregnyl Novarel
Ovidrel
Laxatives Kristalose 10GM packets lactulose syrup
Muscle Relaxants cyclobenzaprine 7.5 mg cyclobenzaprine 5 mg cyclobenzaprine 10 mg
Lorzone 375 mg
Lorzone 750 mg
chlorzoxazone 500 mg
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Arthrotec 75 mg diclofenac/misoprostol
ketoprofen 25 mg ketoprofen 50 mg
ketoprofen 75 mg
ketoprofen ER 200 mg
Nalfon 400 mg
Nalfon 600 mg
fenoprofen 600 mg tablets
naproxen sodium CR 375 mg
naproxen sodium CR 500 mg
naproxen 250 mg
naproxen 375 mg
naproxen 500 mg tablets
naproxen sodium 275 mg tablets
naproxen sodium 550 mg tablets
Ophthalmic Anti-Inflammatory Products Lotemax
Lotemax SM
fluorometholone
loteprednol
prednisolone
Oral Antibiotics doxycycline hyclate 50 mg tablets doxycycline hyclate 20 mg tablets
doxycycline hyclate 50 mg capsules
doxycycline hyclate 100 mg tablets/capsules
doxycycline hyclate 150 mg tablets
Oral Diabetes Treatments ActoPlus MET
ActoPlus MET XR
pioglitazone/metformin
Overactive Bladder Agents Vesicare darifenacin ER
oxybutynin
oxybutynin ER
solifenacin
tolterodine
tolterodine ER
trospium
trospium XR
Parkinson’s Treatments Stalevo carbidopa/levodopa/entacapone
Prenatal Vitamins Azesco
Trinaz
generic prenatal vitamin options1
Topical Actinic Keratosis Treatments Carac 0.50%
Zyclara 2.50%
Zyclara 3.75%
fluororacil cream
fluororacil solution
imiquimod cream
Ulcerative Colitis Treatments Apriso 0.375 GM mesalamine 0.375 GM

1. These products are eligible for $0 copay with a prescription, under the Affordable Care Act.

Medications Excluded from Coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2021. 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.

Medication Name
diclofenac 1% gel1
Niacor 500 mg2
niacin 500 mg IR2
Voltaren 1% gel1
  1. This medication is available over-the-counter without a prescription.
  2. Over-the-counter alternatives that don’t require a prescription are available for this medication.

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 2021 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
Bone Marrow Stimulants Ziextenzo Tier 3a Tier 4a Tier 5a Tier 6a
High-Cost Generic Agents amlodipine/benazepril Tier 2b Tier 3b Tier 2b Tier 3b
carbidopa/levodopa/entacapone Tier 2b Tier 3b Tier 2b Tier 3b
diclofenac/misoprostol Tier 2b Tier 3b Tier 2b Tier 3b
dutasteride/tamsulosin Tier 2b Tier 3b Tier 2b Tier 3b
trandolapril/verapamil Tier 2b Tier 3b Tier 2b Tier 3b
High triglyceride treatments fenofibrate 40 mg, 43 mg, 120 mg, and 130 mg Tier 2b Tier 3c Tier 2b Tier 3c
Topical Antiviral Treatments Acyclovir cream Tier 2b Tier 3b Tier 2b Tier 3b
Acyclovir ointment Tier 1c Tier 1c Tier 1c Tier 1c
  1. This medication was previously covered at Tier 2 and requires step therapy.
  2. This medication was previously covered at Tier 1.
  3. This medication was previously covered at Tier 2.

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
Immunomodulators Actemra 162 mg/0.9 ml syringe 4 syringes
Actemra Actpen 162 mg/0.9 ml 4 pens
Cimzia 200mg vial kit  6 vials
Cimzia 2x200 mg/ml syringe kit  2 kits
Cimzia 2x200 mg/ml start kit  6 syringes
Humira CF 10 mg/0.1 ml syringe  2 syringes
Humira CF 20 mg/0.2 ml syringe  2 syringes
Humira CF 40 mg/0.4 ml syringe  2 syringes
Humira CF Pedi-Crohn’s 80-40 mg kit  2 syringes
Humira CF Pedi-Crohn’s 80 mg/0.8 ml kit  2 syringes
Humira CF Pen 40 mg/0.4 ml 2 pens
Kineret 100 mg/0.67 ml syringe 30 syringes
Olumiant 1 mg tablets  30 tablets
Orencia 50 mg/0.4 ml syringe  4 syringes
Orencia 87.5 mg/0.7 ml syringe  4 syringes
Orencia ClickJect 125 mg/ml autoinjector  4 autoinjectors
Orencia 250 mg vial  4 vials
Otezla 28-day starter pack  55 tablets (1 pack)
Rinvoq ER 15 mg tablets  30 tablets
Stelara 45 mg/0.5 ml vial  1 vial
Stelara 45 mg/0.5 ml syringe  1 syringe
Stelara 90 mg/ml syringe 1 syringe
Topical Antiviral Treatments acyclovir cream two tubes per prescription
Zovirax cream two tubes per prescription
Topical Corticosteroids calcipotriene/betamethasone
dipropionate ointment
120 GM
calcipotriene/betamethasone
dipropionate scalp solution
120 ml
diflorasone 0.05% cream
diflorasone 0.05% ointment
120 GM

 

Medications Requiring Prior Authorization

For certain medications, a member’s doctor must first obtain approval before we cover them. The following medication now requires prior authorization:

Medication Name
Ziextenzo1
  1. Members currently filling prescriptions for this medication may continue to do so without prior authorization.
Looking for More Information?

For more information about any of these medications, use the Medication Lookup tool.

Questions?

If you have any questions, please contact your account executive.

2020 Plan Updates

Effective October 1, 2020, Inflectra Is Now Preferred over Remicade for Members with Existing Prescriptions

Effective October 1, 2020, the immune-modulating medication Inflectra is now the preferred brand-name medication over Remicade. This affects members 18 years and older with existing prescriptions, and applies to prescriptions covered under the medical and pharmacy benefit.

We recently contacted members who are currently taking Remicade to inform them about this coverage change, and encouraged them to talk to their doctors about switching to Inflectra before their prior authorization for Remicade expires. If their doctor determines Remicade is medically necessary, their doctor can request an exception for coverage. If the exception is approved, the member will pay the highest-tier cost when filling the medication under the pharmacy benefit. If filling the medication under the medical benefit, the member will pay their usual out-of-pocket costs.

Prior authorization is required for Inflectra and Remicade prescriptions.

Questions?

If you have any questions, please contact your account executive.

Blue 20/20 Online HR Portal Adds Enrollment Management

We’ve expanded the Blue 20/20 HR portal, currently used by accounts to access invoices, to include online enrollment management. New and existing accounts can soon use Blue 20/20 HR portal to enter enrollment changes, terminations, and additions for members and dependents, and get approval as soon as the same business day. All changes will be reviewed and approved by the Blue 20/20 enrollment team, to ensure accuracy before going live.

This new function will roll out in stages. Effective October 1, 2020, new Blue 20/20 accounts will be able to select online enrollment on the employer application. The Blue 20/20 enrollment team will reach out to the enrollment contact on the application to provide training and answer questions. Accounts can begin using Blue 20/20 HR portal after plan implementation is complete.

Existing accounts will have access to online enrollment after January 1, 2021, upon their anniversary. At that time, the Blue 20/20 account management team will review portal options and assist accounts with signing up.

If you have any questions, please contact your account executive.

Health Plan Updates for 2021

Effective January 1, 2021, and upon renewal, we’re making changes to our portfolio of health plans to ensure we are continuing to provide high-quality, affordable coverage you and your employees expect from Blue Cross.

In 2021, we’ll offer:

  • New plan designs
  • Lower costs for certain insulin medication
  • Certain classes of medications at zero copay

To see how these and our other updates will affect your accounts, please review the relevant documents below:

Accounts with 50 or Fewer Enrolled

  • 2021 Product and Benefit Updates

Accounts with 51–99 Enrolled

  • 2021 Product and Benefit Updates

Accounts with 100 or More Enrolled

  • 2021 Product and Benefit Updates

You can also use our Plan Comparison tool to find, compare, and download plan documents.

Questions?

If you have questions, please contact your account executive.

Personal Protective Equipment Assistance for Dental Blue®´ Providers

For dental services provided from June 1 to August 31, 2020, we’ll be reimbursing our Dental Blue providers in Massachusetts an additional $10 per covered visit. This new reimbursement will help our providers with personal protective equipment (PPE) costs as they returned to practice. PPE is essential to ensuring visits are safe for patients and providers alike.

We’ve introduced these payments to help Massachusetts dentists get back to business, without adding costs for you and our members. These payments will be outside of our normal claims process and won’t count against members’ annual benefit maximum. Please note that members who visit Dental Blue providers should never be billed directly for PPE costs.


Upcoming Prior Authorization Changes for Medications Covered Under the PPO and EPO Medical Benefit

Beginning January 1, 2021, we’re adding Prior Authorization requirements for our members with PPO and EPO plans for certain medications when covered under the medical benefit. Members currently using these medications, and those newly prescribed on or after January 1, 2021, will need an approved authorization to receive coverage. Their doctor can request Prior Authorization for these medications.

To see the full list of medications that will require Prior Authorization, go to the Medication Lookup Tool and select Medical Benefit Prior Authorization Medication List under Important Information.

When coverage is requested for a medication that requires Prior Authorization, we review the request to determine whether the medication is medically necessary. We base the review on the patient’s diagnosis and medication history, as well as U.S. Food and Drug Administration and other evidence-based guidelines.

Prior Authorization is required for these medications when administered:

  • In a clinician’s or physician’s office
  • By a home health care provider
  • By a home infusion therapy provider
  • In an outpatient hospital or dialysis setting

This change doesn’t affect medications received in inpatient, surgical day care, urgent care, and emergency department settings. It also doesn’t apply to members of the following:

  • Federal Employee Program
  • Medex®´
  • Managed Blue for Seniors
  • Medicare*
  • Indemnity

*Some Medicare plans have Prior Authorization requirements for medications. Please see the plan benefits for more details.

Benefits of Prior Authorization

By making these changes, we’re standardizing our Prior Authorization requirements across our HMO, POS, PPO, and EPO plans, resulting in straightforward, effective care. Prior Authorization helps:

  • Ensure that covered medications are safe, effective, and medically necessary
  • Avoid surprise out-of-pocket costs by confirming coverage before getting treatment

Questions?

If you have any questions, please contact your account executive.

Changes to Our Specialty Pharmacy Network for Fertility Medications

Effective August 31, 2020, AcariaHealth™ Fertility will be leaving our specialty pharmacy network for fertility medications. This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF).

Members will be able to complete their current course of treatment with AcariaHealth Fertility; however, specialty fertility medications purchased through AcariaHealth Fertility after August 31, 2020, will no longer be covered. We’ll contact members who fill their prescriptions at AcariaHealth Fertility to let them know that the pharmacy is leaving our specialty fertility network, and help them transition to another in-network specialty pharmacy for fertility medications. This change only applies to AcariaHealth Fertility and our specialty fertility network. AcariaHealth Fertility’s parent company, AcariaHealth, will remain in our specialty pharmacy network.

Specialty pharmacies provide specialty medications that are used to treat certain complex health conditions. For more information about specialty medications, use our Medication Lookup tool.

If you have any questions, please contact your account executive.

Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective October 1, 2020

Effective October 1, 2020, 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. This update includes the changes that were originally scheduled to go into effect on May 1 and July 1. 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
  • Have new quantity or dosing limits
  • Require step therapy

*This doesn’t include Medex 2 plans with Blue MedicareRxTM (PDP) prescription drug coverage

Medications No Longer Covered Starting October 1, 2020

After carefully reviewing each medication's cost and their clinically appropriate covered alternatives, we've removed the medications listed below from our list of covered medications. 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 Medication Name Covered Alternative
Acne (topical) Differin 0.3% gel pump Adapalene 0.3% gel
Retin-A cream Tretinoin cream
Acne (topical)/Psoriasis Fabior 0.1% foam
Tazorac 0.5% and 0.1% cream
Tazorac 0.5% and 0.1% gel
Tazarotene
Analgesics (non-narcotic) Tramadol ER capsules Tramadol ER tablets
Anticonvulsants Depakote
Depakote ER
Depakote Sprinkle
Divalproex
Divalproex ER
Divalproex Sprinkle
Keppra Levetiracetam
Levetiracetam ER
Lamictal
Lamictal ODT
Lamictal XR
Lamotrigine
Lamotrigine ODT
Lamotrigine XR
Topamax Topiramate
Trileptal Oxcarbazepine
Zonegran Zonisamide
Antidepressants Fluoxetine tablets
Venlafaxine ER tablets
Fluoxetine capsules
Venlafaxine ER capsules
Antidepressants/
Nerve Pain
Savella Duloxetine
Pregabalin
Antineoplastics Arimidex Anastrozole
Aromasin Exemestane
Gleevec Imatinib
Aspirin Products Duralaza 81 mg aspirin1
Over-the-counter 325 mg aspirin2
Blood Pressure Nitro-Dur 0.1 mg/hr patch
Nitro-Dur 0.2 mg/hr patch
Nitro-Dur 0.3 mg/hr patch
Nitro-Dur 0.4 mg/hr patch
Nitro-Dur 0.6 mg/hr patch
Nitro-Dur 0.8 mg/hr patch
Nitroglycerin patch
Chemotherapy/
Protective Agent
Fusilev Levoleucovorin
Diabetes Invokamet
Invokamet XR
Invokana
Farxiga
Jardiance
Synjardy
Synjardy XR
Xigduo XR
Erectile Dysfunction (oral) Cialis3
Levitra3
Staxyn3
Stendra3
Viagra3
Sildenafil4
Irritable Bowel Syndrome Treatment Zelnorm Amitiza
Linzess
Motegrity
Migraine Imitrex 6mg/0.5ml injection Sumatriptan 6mg/0.5ml injection
Multiple Sclerosis Treatment Copaxone Glatiramer
Glatopa
Ophthalmic Combinations Tobradex
Zylet
Neomycin/­Bacitracin/­Polymyxin
B/Hydrocortisone,
Neomycin/­Polymyxin
B/Dexamethasone,
Neomycin/­Polymyxin
B/Hydrocortisone,
Sulfacetamide/­Prednisolone,
Tobramycin/­Dexamethasone
Smoking Cessation Zyban 150 mg Bupropion SA 150 mg
Thrombocytopenia Treatment Mulpleta Doptelet

 

  1. This over-the-counter product is eligible for $0 copay with a prescription, under the Affordable Care Act.
  2. This over-the-counter product is excluded from coverage. Exceptions won’t be accepted.
  3. The quantity limit for this medication is 4 units per prescription, unless an exception is approved for more.
  4. The quantity limit is increasing from 4 to 6 tablets per prescription on October 1, 2020.

Compounded Medications Excluded from Coverage

The following compounded medications will be excluded from our pharmacy benefit, effective October 1, 2020. If any of these medications is used as an ingredient in a compounded medication in the exact strength and form listed below, members may be responsible for the full cost of the medication. This change will apply to all medical plans, group Medex* plans with pharmacy benefits, and Managed Blue for Seniors with pharmacy benefits. Formulary exceptions won’t be accepted for these medications.

Medication Class Medication Name Strength and Form
Anticonvulsants Carbamazepine 100 mg chew tablet
200 mg tablet
Antidepressants Amitriptyline 10 mg tablets
25 mg tablets
50 mg tablets
75 mg tablets
100 mg tablets
150 mg tablets
Clomipramine 25 mg capsules
50 mg capsules
75 mg capsules
Imipramine Pamoate 75 mg capsules
100 mg capsules
125 mg capsules
150 mg capsules
Nitroglycerin Nitro-Bid 2% ointment
 

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 higher tier under certain pharmacy plans and may cost more.

Medication Class Medication Name 2020 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
Erectile Dysfunction (oral) Tadalafil Tier 3a Tier 4b Tier 3a Tier 4b
Vardenafil Tier 3a Tier 4b Tier 3a Tier 4b

 

  1. This medication was previously covered at Tier 1.
  2. This medication was previously covered at Tier 2.

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
Antibiotics (topical) Clindamycin Phosphate 1% foam 100 GM
Clindamycin Phosphate 1% gel 150 GM
Clindamycin Phosphate 1% lotion 120 ml
Clindamycin Phosphate 1% solution 60 ml
Clindamycin Phosphate 2% cream 80 GM
Mupirocin 2% cream 60 GM
Mupirocin 2% ointment 44 GM
Anticholinergics (inhaled) Tudorza Pressair 400 mcg inhaler 2 inhalers
Yupelri 175 mcg/3 ml solution 30 vials
Antifungals (topical) Econazole Nitrate 1% cream 170 GM
Ketoconazole 2% cream 120 GM
Ketoconazole 2% shampoo 240 ml
Antimuscarinics (inhaled) Spiriva Handihaler 18 mcg inhaler 30 capsules
Beta Agonists (long-acting, inhaled) Brovana 15 mcg/2 ml solution 120 ml
Perforomist 20 mcg/2 ml solution 60 ml
Combinations (inhaled) Stiolto RespiMat inhaler 1 inhalation cartridge (4 GM)
Corticosteroids (inhaled) Alvesco 80 mcg inhaler 6.1 GM (1 inhaler)
Asmanex Twisthaler 110 mcg,
220 mcg inhaler
1 inhaler
Flovent Diskus 50 mcg, 100 mcg, 250 mcg 60 blisters
Flovent HFA 44 mcg, 110 mcg,
220 mcg
1 inhaler
Pulmicort Flexhaler 90 mcg inhaler 1 inhaler
Pulmicort Flexhaler 180 mcg inhaler 2 inhalers
Pulmicort Respule 0.25 mg/2 ml, 0.5 mg/2 ml 60 ml (30 ampules)
Pulmicort Respule 1 mg/2 ml 30 ml (15 ampules)
QVAR 40 mcg inhaler 10.6 GM (1 inhaler)
SSRI (Antidepressants) Prozac 40 mg, Fluoxetine 40 mg Limits removed1
Zoloft 100 mg, Sertraline 100 mg

 

  1. Quality Care Dosing limits were removed for these medications on July 1, 2020.

Medications That Now Require Step Therapy

Step Therapy is a key part of our Prior Authorization program. It enables us to help doctors provide members with an appropriate and affordable medication treatment. Before coverage is allowed for certain costly “second-step” medications, we require that members first try an effective, but less expensive, “first-step” medication. Some medications may have multiple steps.

The following medications now require Step Therapy. This change only applies to new prescriptions. Members with a claim for any of these medications within the previous 130 days can continue their therapy without interruption.

Medication Class Step 1 Medication Step 2 Medication Step 3 Medication
Migraine Treatment

Naratriptan

Rizatriptan

Sumatriptan

Almotriptan

Eletriptan

Frovatriptan

Sumatriptan/Naproxen

Zolmitriptan

Zomig nasal spray

Amerge

Axert

Frova

Imitrex

Imitrex Injection

Maxalt

Maxalt MLT

Relpax

Treximet

Zomig tablets

 
Looking for More Information?

For more information about any of these medications, use the Medication Lookup tool at bluecrossma.com/medications.

Questions?

If you have any questions, please contact your account executive.


Upcoming 4th-Quarter Changes to the Blue Cross Blue Shield of Massachusetts Formulary

In the fourth quarter of 2020, 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. This update includes changes that were originally scheduled to go into effect on May 1 and July 1. As part of these updates, certain medications may:

  • No longer be covered (exceptions may be granted)
  • Be excluded from coverage (exceptions won’t be granted)
  • Switch tiers
  • Have new quantity or dosing limits
  • Require step therapy

Questions?

Complete details about these changes will be available 60 days before the effective date on bluecrossma.com/employer in the Plan Updates section under What’s New. If you have any questions, please contact your account executive.


Coverage Change for Breast Cancer Risk-Reduction Medications

On October 1, 2020, we’ll begin covering the following generic oral medications in the class of aromatase inhibitors at no additional cost for members when the medications are prescribed to reduce breast cancer risk:

  • Anastrozole
  • Exemestane
  • Letrozole

This change applies to plans with either the Blue Cross Blue Shield of Massachusetts Formulary or the National Preferred Formulary. However, this change doesn’t apply to grandfathered plans that don’t comply with the Affordable Care Act.

If you have any questions, please contact your account executive.


Coverage Update for Truvada

On July 1, 2020, we’ll begin covering Truvada, an HIV pre-exposure prophylaxis (PrEP) medication, at no additional cost for members who aren’t currently filling other HIV medications. Members taking other HIV medications, or are switching from an HIV medication to Truvada, will have to pay their usual out-of-pocket costs, including copays, co-insurance, and deductibles. This change applies to new prescriptions and refills, and to plans with either the Blue Cross Blue Shield of Massachusetts Formulary or National Preferred Formulary. However, the change doesn’t apply to grandfathered plans that don’t comply with the Affordable Care Act.

When the generic version of Truvada is released, we’ll start covering the generic version (instead of Truvada) at no additional cost for members who aren’t currently filling other HIV medications. At that time, members who continue to take Truvada, whether they’re taking additional HIV medications or not, will have to pay their usual out-of-pocket costs, including copays, co-insurance, and deductibles.

If you have any questions, please contact your account executive.


Medications That Now Require Prior Authorization, Effective April 1, 2020

Effective April 1, 2020, until further notice, the following medications will have quantity limits for first-time prescriptions for new therapies:

  • Chloroquine Phosphate
  • Hydroxychloroquine
  • Plaquenil

If a medication is prescribed for more than 10 days, the prescribing doctor will be required to obtain Prior Authorization from us before additional medication can be covered and dispensed.

 If you have any questions, talk to your account executive.


July 1st Formulary Changes Temporarily Delayed

In a recent Important Administrative Information (IAI) newsletter we notified you of upcoming formulary (list of covered medications) changes for July 1st that affected medical plans with pharmacy benefits as well as Medex®' plans with a three-tier pharmacy benefit. These changes have been temporarily delayed.

If you have any questions, talk to your account executive.


May 1st Formulary Changes Temporarily Delayed

We recently notified you of upcoming formulary (list of covered medications) changes for May 1st that affected medical plans with pharmacy benefits as well as Medex® ́ plans with a three-tier pharmacy benefit. These changes have been temporarily delayed.

If you have any questions, talk to your account executive.


Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective May 1, 2020 - DELAYED

Beginning May 1, 2020, 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 these updates, certain medications may:

  • No longer be covered (exceptions may be granted)

Medications No Longer Covered Starting May 1, 2020

After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the table below from our list of covered medications. 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 Medication Name Covered Alternative
Acne (topical) Retin-A cream Tretinoin cream
Antidepressants

Fluoxetine tablets

Venlafaxine ER tablets

Fluoxetine capsules

Venlafaxine ER capsules

Antineoplastics

Arimidex

Aromasin

Gleevec

Anastrozole

Exemestane

Imatinib

Diabetes

Invokamet

Invokamet XR

Invokana

Farxiga

Jardiance

Synjardy

Synjardy XR

Xigduo XR

Migraine Imitrex 6mg/0.5ml injection Sumatriptan 6mg/0.5ml injection
Ophthalmic combinations

Tobradex

Zylet

Neomycin/Bacitracin/Polymyxin B/Hydrocortisone,

Neomycin/Polymyxin B/Dexamethasone,

Neomycin/Polymyxin B/Hydrocortisone,

Sulfacetamide/Prednisolone,

Tobramycin/Dexamethasone

Questions?

If you have any questions, please contact your account executive.


Changes to Our Specialty Pharmacy Network

Effective March 31, 2020, BriovaRx®' will be leaving our specialty pharmacy network. This change applies to the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF). This does not affect members who have Medicare Advantage with a Part D prescription drug plan; they can continue to use BriovaRx without interruption.

Unless they have Medicare Advantage with a Part D plan, members will no longer be covered for specialty medications purchased through BriovaRx. We’ll contact members who fill their prescriptions at BriovaRx to let them know that the pharmacy has left our network, and help them transition to an in-network specialty pharmacy.

Specialty pharmacies provide specialty medications that are used to treat certain complex health conditions. For more information about specialty medications, use the Medication Lookup tool.

If you have any questions, please contact your account executive.


Change to Blue 20/20 Retail Provider Network

Starting February 1, 2020, EyeMed Vision Care®', an independent vision benefits company that administers our Blue 20/20 plans, will no longer contract with Sears Optical, JC Penney Optical, or Stanton Optical. This change in service will have little or no impact on Blue 20/20 members, since these retailers handled less than 1% of members’ claims over the past 24 months. Members will continue to have access to a broad network of providers, including independent, online, and national retailers, such as LensCrafters, Target Optical, and Pearle Vision.

Members who have visited one of these retail locations in the last four years will be notified of the network change and the closest in-network providers in their area.

If you have any questions, please contact your account executive.


January 2020: Upcoming Changes to Our Pharmacy Formulary

Beginning January 1, 2020, we're updating 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 (exceptions may be granted)
  • Be excluded from coverage (exceptions won’t be granted
  • Switch tiers
  • Have new quantity or dosing limits

Medications No Longer Covered in 2020

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 Medication Name Covered Alternative
Epinephrine Injections Adrenaclick (Authorized Generic Product) Epinephrine Auto-Injector
EpiPen Auto-Injector
Inhaled Anticholinergic for chronic obstructive pulmonary disease Tudorza inhaler Spiriva RespiMat 
Spiriva HandiHaler
Laxative Lactulose 10 gm packet Lactulose syrup
Stimulants Strattera* Atomoxetine
Nonsteroidal Anti-Inflammatory Fenoprofen 200 mg and 400 mg capsules Fenoprofen 600 mg tablets
Ophthalmic Dry eye Treatment Restasis MultiDose Restasis Single Use vials (requires prior authorization)
Oral Acne Treatment Doxycycline IR-DR

Doxycycline Hyclate

Doxycycline Monohydrate

Oral Antihistamine Carbinoxamine 6 mg tablets Carbinoxamine 4 mg tablets
Oral Muscle Relaxants Chlorzoxazone 250 mg, 375 mg, and 750 mg tablets Chlorzoxazone 500 mg tablets
Topical Acne Treatment Aktipak gel pouch Erythromycin/Benzoyl Peroxide
Topical Vitamin D Sorilux Foam Calcipotriene Cream
Weight Loss Belviq
Belviq XR
Saxenda
Contrave ER

*If a member currently takes Strattera, their medication will continue to be covered until the current authorization expires. However, the member will pay the highest-tier cost.


Medications Excluded from Coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2020. 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.

Medication or Supply Name
Bensal HP1
Epiduo1
Pliaglis 2
Prilocaine 7%/Tetracaine 7%2
Sil-k 2” X 5” Pad3
Topical Lidocaine 4% strength and under4
  1. Over-the-counter alternatives that don’t require a prescription are available for this medication.
  2. This medication isn’t available over-the-counter and is only available for medical professional use.
  3. Coverage for bandages isn’t included under our pharmacy benefit.
  4. This medication is available over-the-counter without a prescription.

Medications Switching Tiers

When the cost of a medication changes, we may move it to a different tier. The medications listed below are moving to a higher tier under certain pharmacy plans and may cost more.

Medication Class Medication Name 2020 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 Antiviral Acyclovir Ointment Tier 2a Tier 3b Tier 2a Tier 3b
Granulocyte Stimulating Factor Nivestym Tier 3b Tier 4c Tier 5d Tier 6e
  1. This medication was previously covered at Tier 1.
  2. This medication was previously covered at Tier 2.
  3. This medication was previously covered at Tier 3.
  4. This medication was previously covered at Tier 4.
  5. This medication was previously covered at Tier 5.

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, we’re reducing Quality Care Dosing Limits for the following medications:

Medication Name Quality Care Dosing Limit per prescription
Calcipotriene 0.0005% cream, ointment, topical solution 
Dovonex 0.0005% cream, ointment, topical solution
180 gm (all formulations)
Doxepin 5% cream 
Prudoxin 5% cream
Zonalon 5% cream
90 gm total
Albuterol HFA authorized products 
ProAir HFA 
ProAir RespiClick 
Ventolin HFA 
Proventil HFA 
Xoponex HFA
2 inhalers
Oxiconazole nitrate 1% cream
Oxistat cream
90 gm each
Triamcinolone 0.147mg/spray aerosol
Kenalog aerosol (T3)
2 aerosol cans (126 gm)

Expanded Access to Certain Cholesterol Medications

In 2020, members will be able to fill prescriptions for Praluent and Repatha at any retail pharmacy that has access to these medications in the Express Scripts®´ network.* Previously, these medications, which are known as PCSK9 agents and are typically used to lower cholesterol levels, were only available through in-network specialty pharmacies.

*Please note that these medications may not be available at all pharmacies.


Health Plan Updates for 2020

Effective January 1, 2020, 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 2020, we’ll offer:

  • Acupuncture Coverage—Members covered for up to 12 acupuncture visits per calendar year
  • New Higher Deductible Plan Designs—More options for members, greater customization for employers
  • Expanded Pharmacy Coverage—Making many prescription medications more affordable and accessible
  • Redesigned Fitness and Weight-Loss Reimbursements—New guidelines for reimbursements, so that more members can earn up to $150 per calendar year

To see how these and our other updates will affect you, please review the relevant documents below:

Accounts with 50 or Fewer Enrolled

  • 2020 Product and Benefit Updates
  • 2020 HMO Product Coverage Options
  • 2020 PPO Product Coverage Options

Accounts with 51–99 Enrolled

  • 2020 Product and Benefit Updates
  • 2020 HMO Product Coverage Options
  • 2020 PPO Product Coverage Options

Accounts with 100 or More Enrolled

  • 2020 Product and Benefit Updates
  • 2020 HMO Product Coverage Options
  • 2020 PPO Product Coverage Options

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.

2019 Plan Updates

Blue Cross Blue Shield of Massachusetts Surpassed 2018 Medical Loss Ratio Requirements

In 2018, Blue Cross Blue Shield of Massachusetts exceeded the state and federal medical loss ratio (MLR) requirements for all market segments. As a result, we don’t need to issue account rebates for 2018.

Each year, the Patient Protection and Affordable Care Act (PPACA) requires insurers to meet certain MLR standards. Insurers who don’t meet these requirements must issue rebates to eligible accounts. We’re proud to have surpassed these requirements for 2018.

If you have questions, please contact your account executive or visit healthcare.gov or mass.gov to learn more about MLR.


Weight-Management Program StepIn®´´ Available for Select Self-Funded Accounts

Effective January 1, 2020, StepIn, a new weight-management program, will be included at no additional cost for self-funded accounts with pharmacy benefits who have enrolled in the Diabetes Care Value program. The program helps members* with chronic health conditions, such as prediabetes, high blood pressure, and high cholesterol, manage their weight. Members who enroll will get:

  • Unlimited one-on-one coaching
  • A smart scale that syncs to a mobile app
  • A personalized health plan tailored to their goals and lifestyle
  • Access to a peer support group, and guided mini challenges

Self-funded accounts that want to add StepIn should contact their account executive about enrolling in the Diabetes Care Value program.

 StepIn is available through Livongo®´´, an independent health management company, and offered by Blue Cross Blue Shield of Massachusetts in partnership with Express Scripts®´´, an independent company that administers your pharmacy benefits and the Diabetes Care Value program.

*Members are identified based on pharmacy claims data through Express Scripts, Inc.


Updates to Our Dental Blue® Total Health Solution

Starting September 1, 2019 for new and renewing accounts, we’re offering an expanded list of chronic conditions that qualify members for Enhanced Dental Benefits. The updated list will include stroke and Sjogren’s Syndrome. Members with qualifying conditions who have both medical and dental coverage are automatically enrolled in this program.

With this update, qualifying conditions now include: 

  • Diabetes
  • Coronary Artery Disease
  • Stroke
  • Pregnancy
  • Oral Cancer
  • Sjogren’s Syndrome

Additional Support for Qualifying Members

Our Enhanced Dental Benefits offer additional, specific support, including full coverage for preventive and periodontal services that have been connected to improved overall health. Please see the table below for coverage details for members with qualifying conditions.

Condition One cleaning or
periodontal
maintenance visit
every 3 months
Periodontal
scaling once per
quadrant every 24
months*
Oral cancer
screening once
every 6 months
Fluoride
treatment every 3
months
Diabetes • •    
Coronary Artery
Disease
• •    
Stroke** • •    
Pregnancy • •    
Oral Cancer •   • •
Sjogren’s
Syndrome**
•   • •

*Periodontal Maintenance and scaling are available on plans that offer periodontal benefits.
** Stroke and Sjogren’s Syndrome are conditions being added to benefits on renewal starting 9/1/2019.

Enhanced dental benefits are fully covered and are not subject to a deductible, co-insurance, or calendar-year maximum when a member visits a participating in-network dentist.

For more information, please see the Dental Blue® Total Health Solutions Employer Fact Sheet.

Questions?

If you have any questions, please contact your account executive.

One cleaning or periodontal maintenance visit every 3 months

Condition ❘ Diabetes
Condition ❘ Coronary Artery Disease
Condition ❘ Stroke**
Condition ❘ Pregnancy
Condition ❘ Oral Cancer
Condition ❘ Sjogren’s Syndrome**

Periodontal scaling once per quadrant every 24 months*

Condition ❘ Diabetes
Condition ❘ Coronary Artery Disease
Condition ❘ Stroke**
Condition ❘ Pregnancy

Oral cancer screening once every 6 months

Condition ❘ Oral Cancer
Condition ❘ Sjogren’s Syndrome**

Fluoride treatment every 3 months

Condition ❘ Oral Cancer
Condition ❘ Sjogren’s Syndrome**

 


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

 

  • Cinqair
  • Fasenra
  • Nucala
  • Neupogen
  • Neulasta
  • Haegarda
  • Berinert
  • Firazyr
  • Kalbitor
  • Ruconest

Prior authorization is required for these medications when administered:

  • In a clinician’s or physician’s office
  • By a home health care provider
  • By a home infusion therapy provider
  • In an outpatient hospital and dialysis settings

Medication Name

  • Cinqair
  • Fasenra
  • Nucala
  • Neupogen
  • Neulasta
  • Haegarda
  • Berinert
  • Firazyr
  • Kalbitor
  • Ruconest

Administration

Prior authorization is required for these medications when administered:

  • In a clinician’s or physician’s office
  • By a home health care provider
  • By a home infusion therapy provider
  • In an outpatient hospital and dialysis settings

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.

2018 Plan Updates

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
Hepatitis 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.

2017 Plan Updates

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

2017 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.


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.

Blue Cross Blue Shield of Massachusetts

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ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación llamada 1-800-200-4255 (TTY: 711 ).

ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID chamar  1-800-200-4255 (TTY: 711 ).

ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré appel 1-800-200-4255  (TTY : 711 ).

注意:如果您讲中文,我们可向您免费提供语言协助服务。请拨打您 ID  卡上的号码联系会员服务部 通话 1-800-200-4255(TTY  号码:711 )。

ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan Rele 1-800-200-4255 TTY: 711 ).

LƯU .: Nếu quý vị n.i Tiếng Việt, c.c dịch vụ hỗ trợ ng.n ngữ được cung cấp cho quý vị miễn ph.. Gọi cho Dịch vụ Hội vi.n theo số tr.n thẻ ID của quý vị Cuộc gọi 1-800-200-4255 (TTY: 711 ).

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ការជូនដំណឹង៖ ប្រសិនប. ើអ្នកនិយាយភាសា ខ្មែរ សេ  វាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសម្  រាប ់អ្នក។ សូមទូរស័ព្ទទ ៅផ ្នែ កសេ  វាសមា  ជិកតាមល េខន  ៅល.  ើប ័ណ្ណ សម្  គាល ់ខ្លួ ខ្លួ នរប ស់អ្នក ហៅ  1-800-200-4255 (TTY: 711) ។

ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa chiamata  1-800-200-4255 (TTY: 711 ).

참고 : 한국어를 사용하는 경우 언어 지원 서비스를 무료로 사용할 수 있습니다. 신분증에있는 전화 번호 1-800-200-4255 (TTY : 711)로 회원 서비스에 연락하십시오.

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ध्यान दें: य दि  आप ह िन् दी बोलते ह ैं, तो भा षा  सहाय  ता  सेवा एँ, आप के लि ए नि :शुल्क  उपलब्ध ह ैं। सदस्य  सेवा ओं को आपके आई.डी. कार  ्ड पर दि ए गए नंबर पर कॉल करें  कॉल 1-800-200-4255 ( टी .टी .वा ई.: 711).

ધ્યાન આપો:  જો તમે ગુજરા તી બોલતા  હો, તો તમને ભા ષા કીય  સહાય  તા  સેવા ઓ વિ ના  મૂલ્યે  ઉપલબ્ધ છે. તમા રા  આઈડી કાર  ્ડ પર આપેલા  નંબર પર Member Service  ને કૉલ કરો કૉલ કરો 1-800-200-4255 (TTY: 711).

PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card tumawag 1-800-200-4255 (TTY: 711 ).

お知らせ:日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。ID カードに記載の電話番号を使用してメンバーサービスまでお電話ください 呼び出す 1-800-200-4255(TTY: 711 )。

ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an Anrufen 1-800-200-4255 (TTY: 711 ).

ATTENTION: If you speak a language other than English, language assistance services are available to you free of charge. Call 1-800-200-4255 (TTY: 711).

ຂໍ້ຄວນໃສ່ໃຈ: ຖ້າເຈົ້າເວົ້າພາສາລາວໄດ້, ມີການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໃຫ້ທ່ານໂດຍບໍ່ເສຍຄ່າ. ໂທ ຫາ ຝ່າຍບໍລິການສະ ມາ ຊິກທີ່ໝາຍເລກໂທລະສັບຢູ່ໃນບັດຂອງທ່ານ ໂທ 1-800-200-4255 (TTY: 711).

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