Effective January 1, 2022, Coverage Changes for Infused or Injectable Medications Under the Medical Benefit

Blue Cross Blue Shield of Massachusetts is committed to covering infused or injected medications under the medical benefit for our members in the most cost-effective, clinically appropriate setting. We previously communicated that we would implement coverage changes for infused or injectable medications under the medical benefit on September 1, 2021. Blue Cross has decided to delay the implementation of this coverage change until January 1, 2022. We will provide updates to our members prior to the new implementation date, as appropriate. There is no further action needed for members who have already received prior authorization for their infused or injectable medication, or transitioned their care. Members and providers may also choose to initiate a request before the new effective date.

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Quality Care Cancer Program Launching in 2021

We’re launching our new Quality Care Cancer Program on July 1, 2021, to help ensure that our members receive cancer care that is appropriate and safe, based on clinical guidelines. Through the Quality Care Cancer Program, board-certified oncologists and oncology-trained nurses will be available to discuss covered treatment options with our members’ doctors.

Our Quality Care Cancer Program applies to all commercial and Medicare Advantage plan members seeking outpatient medical oncology treatment (chemotherapy, immunotherapy, and supportive medications), or outpatient radiation oncology treatment. Doctors who order these types of treatments for our members will request Prior Authorization through AIM Specialty Health^®´ (AIM), an independent company that will administer this program.

When a member’s oncology care team submits a treatment plan for Prior Authorization that meets evidence-based clinical criteria for the cancer being treated, the member’s doctor will get real-time approval. If the requested treatment doesn’t meet evidence-based criteria, the member’s doctor can request a peer-to-peer consultation with an AIM oncologist to discuss the covered, evidence-based treatments that are best for the member.

For a member already receiving cancer treatment at the time of the Quality Care Cancer Program’s launch, their doctor will need to request a Prior Authorization for the continuation of coverage. If a member’s treatment plan changes, their doctor will then request a new Prior Authorization for health plan coverage.

Because scientific and medical advances are rapidly changing cancer treatment, and there are wide variations in the way doctors treat patients with the same type of cancer, cancer care quality programs like ours are becoming necessary.

The Quality Care Cancer Program is designed to help our members receive the most appropriate and effective treatment regimen, so they can have the best possible outcome with the least number of side effects. If you have any questions, please contact your account executive.

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Changes to the Telehealth Benefit

Starting on July 1, 2021, we will reinstate standard member costs for non-COVID medical- and mental-telehealth visits. How much the member will pay depends on the health plan’s benefits. Medicare members are excluded from this change.

Since March 2020, we voluntarily and temporarily waived member costs for non-COVID telehealth visits to help ensure member access to health care services and to help prevent COVID-19 infection and illness. With the successful roll out of vaccines and the re-opening of states and businesses, this accommodation will end on July 1, 2021.

We will continue to waive costs for covered COVID-19 telehealth services as well as for COVID-19 in-person services when applicable. This includes COVID-19 vaccines.

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Upcoming Coverage Changes for Infused or Injectable Medications Under the Medical Benefit - DELAYED TO JANUARY 1, 2022

Effective September 1, 2021, we’re changing the covered sites of service where members can get infused or injectable medications administered. We’re also requiring prior authorization for these sites, as well as the medications listed below. These changes ensure that members are receiving care in clinically-appropriate, cost-effective settings.

Where to Get Infused or Injectable Medications

Starting September 1, 2021, infused or injectable medications will be covered at the following sites of service and require prior authorization:

• Doctor’s office
• Ambulatory infusion site
• Home infusion therapy provider

Infused or Injectable Medications That Require Prior Authorization

The following medications will require prior authorization when they’re administered in one of the sites of service listed above. These medications will require prior authorization in order to be covered. If prior authorization is already in place, the doctor won’t need to submit a new request until the current authorization expires.

Medications That Currently Require Prior Authorization*		Additional Medications That Will Require Prior Authorization Starting September 1, 2021
Aralast	Lemtrada	Aldurazyme
Berinert	Onpattro	Benlysta
Cerezyme	Prolastin	Crysvita
Cinqair	Ruconest	Duopa
Cinryze	Soliris	Elaprase
Elelyso	Tysabri	Fabrazyme
Entyvio	Ultomoris	Krystexxa
Exondys 51	Uplinza	Lumizyme
Givlaari	Viltepso	Naglazyme
Glassia	VPRIV	Ocrevus
Haegarda	Vyepti	Radicava
Ilumya	Vyondys 53	Vimizim
Kalbitor	Xolair
Kanuma	Zemaira

 

^*Additional clinical criteria must be met to receive coverage for these medications.

What This Means for Your Employees' Coverage

As a result of these changes, members may need to change where they will receive their infused or injectable medications to maintain coverage after September 1. If the prescribing doctor determines that treatment must be done in an outpatient hospital setting, they can contact us to request an exception.

Members Without Prior Authorization		Members With Prior Authorization
-    Members who are receiving infused or injectable medications in an outpatient hospital setting and don’t have an authorization on file must switch to a covered site listed above and their doctor must request prior authorization to maintain coverage. -    Members currently receiving infused or injectable medications at a covered site listed above that don’t have prior authorization on file must have their prescribing doctor request authorization to maintain coverage. We’ll contact these members in advance to help transition them to a covered site of service.		-    Members currently receiving infused or injectable medications with prior authorization on file may complete their approved course of treatment. However, a new authorization will be required for further treatment.   We’ll reach out to these members to let them know that their doctor must request a new prior authorization to maintain coverage after their current approved course ends.

 

This change will apply to all medical plans except for the following plan types:

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

Questions?

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

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

Beginning July 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)
• Have new quantity or dosing limits
• Require prior authorization

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

Medications No Longer Covered Starting July 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
Migraine Treatment		Allzital 25 mg/325 mg tablets	Butalbital/Acetaminophen 25 mg/325 mg tablets
Narcotic Analgesics**		Oxycodone ER Oxycontin 10 mg tablets Oxycontin 15 mg tablets Oxycontin 20 mg tablets Oxycontin 30 mg tablets Oxycontin 40 mg tablets Oxycontin 60 mg tablets Oxycontin 80 mg tablets	Xtampza ER 9 mg capsules Xtampza ER 13.5 mg capsules Xtampza ER 18 mg capsules Xtampza ER 27 mg capsules Xtampza ER 36 mg capsules
Prenatal Vitamin		Azeschew tablets	Mynatal Mynatal Advance Mynatal Plus Prenatabs FA Prenatabs Rx Trinate
Tetracycline Antibiotic		Minocycline 50 mg tablets Minocycline 75 mg tablets Minocycline 100 mg tablets	Minocycline 50 mg capsules Minocycline 75 mg capsules Minocycline 100 mg capsules

 

**The covered alternatives for Narcotic Analgesics will be added to our formulary on April 1, 2021.

 

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
Topical Antibiotic		Gentamicin 0.1% cream		30 grams
		Gentamicin 0.1% ointment		30 grams
Topical Antibiotic/Corticosteroid Combination		Iodoquinol/Hydrocortisone/Aloe gel		48 grams
Topical Antifungal		Ciclopirox 0.77% cream		90 grams
		Ciclopirox 0.77% gel		100 grams
		Ciclopirox 1% shampoo		120 mL
		Ciclopirox 0.77% topical suspension		90 mL
		Nystatin, Nyamyc, Nystop 100,000 units/gram powder		60 grams
Topical Antiviral		Denavir 1% cream		10 grams
Topical Corticosteroids		Halobetasol propionate 0.05% cream		50 grams
		Halobetasol propionate 0.05% ointment		50 grams
Topical Immunosuppresive		Pimecrolimus 1% cream		120 grams

 

Medications Requiring Prior Authorization

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

Medication Class
Fulphila		Granix	Nivestym
Riabni		Ruxience	Truxima
Udenyca		Zarxio	Ziextenzo

 

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.

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Coverage for Certain Infused Oncology Medications Moving to the Medical Benefit

Effective July 1, 2021, the infused oncology medications listed below will only be covered under our medical benefit through the Quality Care Cancer Program. Medications in this program will require prior authorization from AIM Specialty Health^®´´ (AIM), an independent company, and will no longer be included in our pharmacy benefit.

Oncology Medications That Will Be Covered Under Our Medical Benefit
Abraxane	Herceptin	Onivyde
Arzerra	Herceptin Hylecta	Ontruzant
Bavencio	Herzuma	Opdivo
Cyramza	Imfinzi	Poteligeo
Doxil/Lipodox	Kanjinti	Proleukin
Empliciti	Keytruda	Rituxan-Hycela
Fusilev	Khapzory	Tecentriq
Gazyva	Ogivri	Trazimera

 

The Quality Care Cancer Program, which is administered by AIM, launches July 1, 2021. Learn more about this program, which helps ensure the cancer treatments we cover are safe and appropriate for our members, here.

 

This change only applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex^®´ plans^* with a three-tier pharmacy benefit. This change doesn’t apply to group Medicare Advantage and Federal Employee Program plans. Members who receive only medical benefits from Blue Cross can receive coverage for these medications under their medical plan, and may reach out to their pharmacy benefits manager to see if the medications are covered under their pharmacy plan.

Members of affected plans who are currently filling these medications under the pharmacy benefit will be allowed to complete their treatment course without interruption of their coverage.

Questions?

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

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

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Effective July 1, 2021, New Opioid Safety Review to Be Implemented at Pharmacies

Effective July 1, 2021, pharmacists filling a member’s opioid prescription will be alerted if the member may be receiving a total level of opioids that’s potentially unsafe. This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex^®’ plans* with a three-tier pharmacy benefit and Managed Blue for Seniors plans.

Under this safety review, when a pharmacist is filling a member’s opioid prescription, they’ll receive a real-time alert if the member’s total opioid dose across all opioid or opioid-containing prescriptions reaches or exceeds 90 morphine milligram equivalents (MME) per day. If the pharmacist determines the opioid dose is appropriate for care, they can fill the prescription. However, if they believe there could be a safety issue, they may choose not to fill the prescription.

If the pharmacist doesn’t fill the prescription, the member’s prescribing doctor can contact Blue Cross to request authorization for coverage. If authorized, coverage will be approved for up to one year. However, one of the following must be true for the request to be approved:

• The member has a diagnosis of cancer.
• The member is receiving opioids as part of palliative care.
• The prescriber says that the amount of opioid prescribed is necessary for adequate pain management, based on the member’s clinical circumstances.

This safety review doesn’t apply to prescriptions written by in-network oncologists, palliative care providers, and pain management specialists.

Questions?

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

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

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New Prior Authorization Requirements for Select Medications Under the Medical Benefit

Starting July 1, 2021, the medications below are being added to our utilization management program, and will require prior authorization when administered in the following outpatient settings:

• Doctor’s office
• Home health care provider
• Home infusion therapy provider (if prior authorization is in place, no additional authorization is required until the member’s existing authorization expires)
• Outpatient hospital and dialysis settings

Medications That Require Prior Authorization
Mvasi	Riabni	Ruxience	Truxima	Zirabev

 

When these medications are prescribed for oncology treatment, they must be submitted through the Quality Care Cancer Program, which launches July 1, 2021. When prescribed for non-oncology use, these medications will be subject to the current prior authorization process.

 

This change doesn’t affect these medications in inpatient, surgical day care, urgent care centers, and emergency department settings. It also doesn’t apply to Indemnity, Managed Blue for Seniors, group Medicare Advantage, group Medex^®´, and Federal Employee Program plans.*

For more information, talk to your account executive.

^*Members should check their plan details for their plan’s utilization management requirements, if applicable.

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Upcoming Coverage Changes for Certain Medications Moving from Our Medical to Pharmacy Benefit

Effective July 1, 2021, coverage for the following medications will move out of our medical benefit and only be included under our pharmacy benefit.

Medications Moving from Our Medical to Pharmacy Benefit
Available at Retail Pharmacies	Durolane*	Gel-One*	GelSyn-3*
	Monovisc*	Triluron*	Trivisc*
Must Be Filled at a Specialty Pharmacy	Bynfezia	Cosentyx*	Dupixent*
	Fasenra*	Kevzara*	Nucala*
	Siliq*	Strensiq	Tegsedi*
	Tremfya*

 

Members who have plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex^®’ plans** with a three-tier pharmacy benefit, or the National Preferred Formulary*** will receive coverage for these medications under their pharmacy benefit upon the effective date. Members with these plans will not experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit.

 

We’ll contact affected members about this change and help them transition their prescription to support uninterrupted coverage. Members who don’t receive pharmacy coverage from Blue Cross should reach out to their pharmacy benefits manager for coverage details on these medications.

This change will apply to all medical plans, except Managed Blue for Seniors, group Medicare Advantage, group Medex^®´, and Federal Employee Program plans. Group Medex plans with a three-tier benefit will include coverage for these medications under both the medical and pharmacy benefit.

This change doesn’t apply when these medications are administered in inpatient, surgical day care, ambulatory surgery center, and emergency department settings.

Questions?

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

*These medications require prior authorization.
**This doesn’t include Medex 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
***Plans with the National Preferred Formulary may have additional coverage requirements for these medications.

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Updates to Preventive Dental Benefits

On June 1, 2020, as part of our effort to support members during COVID-19, we relaxed the limits on the following preventive dental benefits: routine cleanings, periodic exams, and fluoride treatment. The changes allow members greater flexibility with access to these benefits twice in a calendar year rather than once every 6 months.

Beginning April 1, 2021, upon account renewal, the changes listed above will become standard benefits.

In addition, bitewing x-rays and certain benefits included in our Total Health Solution will be updated. The updated benefits are as follows:

• Bitewing x-rays twice per calendar year
• Total Health Solution Enhanced Dental Benefits:
  • Routine and/or Periodontal Maintenance Cleanings four times per calendar year
  • Oral Cancer Screening twice per calendar year
  • Fluoride Treatment four times per calendar year

These changes apply to Commercial Group Dental Plans 51+

For more information or for self-insured accounts that want to pursue a non-standard benefit frequency, please contact your account executive.

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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.

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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.

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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.

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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.

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.

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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 MedicareRx^TM (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.

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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.

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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.

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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.

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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.

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July 1^st 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 1^st 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.

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May 1^st Formulary Changes Temporarily Delayed

We recently notified you of upcoming formulary (list of covered medications) changes for May 1^st 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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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)

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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.

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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.

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.

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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.

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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.

 

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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.

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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.

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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.

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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

This change doesn’t affect these medications when administered in inpatient care, surgical day care, urgent care centers, and emergency room settings.

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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

*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

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*

*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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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 

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Coming in July 2018: Changes to Our Pharmacy Program

Beginning July 1, 2018, we're making changes to our covered medications list for medical plans with pharmacy benefits, and Medex^®' plans with the three-tier pharmacy benefit. These changes affect:

• Medications switching tiers
• Medications that are no longer covered
• Medication dosing limits

Medications Switching Tiers

When the cost of a medication changes, we move the medication to a different tier. Depending on the tier change, member payments for the following medications may increase or decrease:

Medication Class	Medication Name	New Tier as of July 1, 2018 (applies to 3-tier or 5-tier pharmacy benefits)	New Tier as of July 1, 2018 (applies to 4-tier or 6-tier pharmacy benefits)
Dermatological	Doxepin cream	Tier 21	Tier 32
Inhaled combination for chronic obstructive pulmonary disease	Anoro Ellipta	Tier 21	Tier 32

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

Medications No Longer Covered

After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list. However, when these medications are medically necessary, a member's doctor or prescriber may request a coverage exception.

Medication Class	Non-Covered Medication or Supply	Covered Alternative
Multi-Source Brands	Provigil Lidoderm Patch	Modafinil Lidocaine Patch

Medications with New Dosing Limits

To ensure the quantity and dose of a medication meets the Food & Drug Administration's regulations, manufacturer's guidelines, and clinical recommendations, we're adding a Quality Care Dosing Limit to the following medications:

For This Medication	The Quality Care Dosing Limit Per Prescription	Additional information
Naloxone Carpuject (vial and syringes	Two per 30 days	We're also making this available at no cost beginning 6/1/18 for Fully Insured Accounts, so our members have access to this medication. If your employees are on a Saver plan, the deductible will still apply first.
Narcan nasal spray	Two per 30 days
Evzio	Two per 30 days	N/A

Proton Pump Inhibitors Will Be Excluded from Pharmacy Coverage In 2019

Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. Pylori.

This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We'll notify impacted members beginning in November 2018 prior to the change.

Health Plans for Account Sizes

Beginning January 1, 2018, we'll implement changes to our health plans. These changes will ensure that our plans continue to meet the ongoing requirements of the Affordable Care Act (ACA), while continuing to provide high-quality, affordable health coverage options. We're also excited to soon offer new plan options.

To see how these changes will affect you, please review the documents below for your account size.

Small Accounts (50 or fewer enrolled)

2018 Product and Benefit Updates

2018 HMO Product Coverage Options

2018 PPO Product Coverage Options

Mid-size (51-99 enrolled)

2018 Product and Benefit Updates

2018 HMO Product Coverage Options

2018 PPO Product Coverage Options

Large (100 or more enrolled)

2018 Product and Benefit Updates

2018 HMO Product Coverage Options

2018 PPO Product Coverage Options

You can also find, compare, and download plan documents with our Plan Comparison Tool.

If you have questions, please contact your account executive.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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Changes to Out-of-Network Provider Claims Reimbursement

To reduce exposure to high, out-of-network provider charges, Blue Cross Blue Shield of Massachusetts is enhancing the standard out-of-network provider reimbursement approach for fully insured PPO plans. For out-of-network provider claims processed on and after January 1, 2018, Blue Cross will calculate most out-of-network claim payments based on 150 percent of the Medicare fee schedule. When no Medicare fee is available, Blue Cross will calculate the claim payment based on an amount determined by using current, publicly–available data reflecting fees typically reimbursed for the service, adjusted for geographic variations. Currently, the standard approach relies on the Blue Cross indemnity fee schedule to price these out-of-network claims. As a result of this change, use of the Blue Cross indemnity fee schedule as the standard approach for out-of-network reimbursement purposes will be eliminated.

These changes will be incorporated into PPO subscriber certificates upon the 2017 renewal.

Fully insured PPO accounts for which out-of-network claims currently are paid using a non-standard approach, will be migrated to the new standard out-of-network reimbursement approach upon their 2018 renewal, unless at that time Blue Cross approves use of provider charges as a non-standard benefit.

Out-of-network reimbursement changes also are being developed for ASC PPO plans and will be addressed in a future communication.

For more information, please contact your account executive.

Beginning January 1, 2017, we’ll implement changes to our health plans. These changes will ensure that our plans continue to meet the ongoing requirements of the Affordable Care Act (ACA), while continuing to provide high-quality, affordable health coverage options. We're also excited to soon offer new plan options.

To see how these changes will affect you, please review the documents below for your account size.

Small Accounts (50 or fewer enrolled)

2017 Product and Benefit Updates

2017 HMO Blue New England Product Coverage Options

2017 PPO Product Coverage Options

Mid-size (51-99 enrolled)

2017 Product and Benefit Updates

2017 HMO Blue New England Product Coverage Options

2017 PPO Product Coverage Options

Large (100 or more enrolled)

2017 Product and Benefit Updates

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.

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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.

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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.