UPDATE - Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered

Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts. 

CVS Caremark^®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF. 

To see the 2023 SC-ACSF medication lists, go to the Medication Lookup tool.

CaremarkPCS Health, LLC (“CVS Caremark”) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Effective January 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary

Effective January 1, 2023, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

• No longer be covered (exceptions may be granted)
• Be excluded from coverage (exceptions won’t be granted)
• Switch tiers
• Require prior authorization and/or step therapy

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

Medications No Longer Covered Starting January 1, 2023

After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.

1. This medication also has prior authorization and/or step therapy requirements.
2. Members currently using this medication will continue to be covered until their prior authorization expires.
3. Members using this medication will experience a copay increase as of January 1, 2023.

 Medications Excluded from Coverage

Certain medications will be excluded from our pharmacy benefit, effective January 1, 2023. Members will be responsible for the full cost of these medications when filling a prescription at the pharmacy. This change will apply to all commercial plans, group Medex^®´plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications. We’ll contact members who will be affected by this change.

To find out if a medication is excluded from coverage, effective January 1, 2023, use the Medication Lookup tool.

Medications Switching Tiers

When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease. This isn’t a complete list of medications switching tiers, and we’ll contact members who will be affected by this change.

To find out which tier a medication is in, effective January 1, 2023, use the Medication Lookup tool.

* This medication also has prior authorization and/or step therapy requirements.

1. This medication was previously covered at Tier 3.
2. This medication was previously covered at Tier 4.
3. This medication was previously covered at Tier 5.
4. This medication was previously covered at Tier 6.
5. This medication was previously non-covered.

Medical Policy Updates

Blue Cross medical policies are developed by using evidence-based information to define the technologies, procedures, and treatments that are considered medically necessary, or not medically necessary, or investigational. We use pharmacy medical policies to describe how we cover certain medications. We’re updating the policies listed below. These changes include:

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
• Prior authorization requirements for specific medications to ensure the prescribing doctor has determined that a medication is necessary to treat a member, based on specific medical standards.

Looking for More Information?

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

Questions?

If you have any questions, contact your account executive.

Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary Will Be Offered

Effective January 1, 2023, the Standard Control with Advanced Control Specialty Formulary (SC-ACSF) will be a new formulary (list of covered medications) available to select self-insured plans (500+) with pharmacy benefits. The SC-ACSF will be replacing the National Preferred Formulary (NPF). The NPF will no longer be offered through Blue Cross Blue Shield of Massachusetts.

CVS Caremark^®', an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will be the new pharmacy benefit manager administering the SC-ACSF.

The list of covered medications under the SC-ACSF will be available by October 24, 2022, in the What’s New section.

CaremarkPCS Health, LLC (“CVS Caremark”) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

What’s New for 2023

Choosing the right health plan is essential to attracting and retaining top talent. Effective January 1, 2023, and upon renewal, we’re enhancing our health plan offering to not only meet ongoing requirements but also the market demand to provide high-quality, more affordable coverage you expect from Blue Cross.

In 2023, we’ll offer:

• Solutions that drive value and address affordability
• Virtual Care Team – a new feature in most of our plans at no additional cost providing members a coordinated, virtual primary care experience
• New plans designed for lower premiums
• New Pharmacy Benefit Manager to help:
  • Keep pharmacy costs down for accounts and members
  • Provide more in-network pharmacy locations
  • Offer new pharmacy programs that drive better health outcomes for members

For more details on these new offerings, read the 2023 Product Brochures.

Accounts with 50 or Fewer Enrolled

Accounts with 51–99 Enrolled

Accounts with 100 or More Enrolled

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

Questions?

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

UPDATE - Effective July 1, 2022, Medications No Longer Covered Under the National Preferred Formulary

Effective July 1, 2022, Express Scripts, Inc.^®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for medical plans with the National Preferred Formulary (NPF). Included in this update are medications that will no longer be covered under the NPF.

After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, Express Scripts is removing medications from their formulary. However, a doctor may request an exception if these medications are medically necessary. If the exception is approved by Blue Cross, the member will pay the highest-tier cost.

View Medications

Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Pharmacy Medical Policy Updates

Effective July 1, 2022, we’re updating the Blue Cross Blue Shield of Massachusetts formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans with a three-tier pharmacy benefit.* As part of the formulary update, certain medications are switching tiers.

We’ve also discontinued a medical policy as of March 1, 2022, and we’re making additional medical policy changes on April 1, 2022 and July 1, 2022.

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

Medications Switching Tiers

When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease.

1. This medication was previously covered at Tier 3.
2. This medication was previously covered at Tier 4.
3. This medication was previously covered at Tier 5.
4. This medication was previously covered at Tier 6.

Pharmacy Medical Policy Updates

Pharmacy medical policies are evidence-based documents that we develop to define the technologies, procedures, and treatments that are considered medically necessary; not medically necessary; and investigational. We use pharmacy medical policies to describe how we cover certain medications. We’re updating the following policies:

Learn More About Medications

Use the Medication Lookup tool to learn more about coverage for these medications.

Questions?

If you have any questions, contact your account executive.

Effective July 1, 2022, Medications No Longer Covered Under the National Preferred Formulary

Effective July 1, 2022, Express Scripts, Inc.^®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, is updating their formulary (list of covered medications) for medical plans with the National Preferred Formulary (NPF). Included in this update are medications that will no longer be covered under the NPF.

After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, Express Scripts is removing medications from their formulary. However, a doctor may request an exception if these medications are medically necessary. If the exception is approved by Blue Cross, the member will pay the highest-tier cost.

Complete details about these changes will be available by April 26, 2022 in the What’s New section.

Update on Coverage Change for Infused, Injectable Medications Under the Medical Benefit, Effective January 1, 2022

We previously notified you that we planned to change the covered sites of service where members can have their infused or injectable medications administered. We’ve decided to make Site of Care a voluntary program rather than a requirement.

Voluntary Site of Care Program

The Voluntary Site of Care Program is designed to promote the use of infused and injected medications in the most cost-effective, clinically appropriate setting. Making this a voluntary program gives members a choice of where they receive their care.

We believe that our Voluntary Site of Care Program is clinically sound, safe, and cost-effective for most of our members, and that other health risks are mitigated when care is provided at alternate sites.

What This Means for Your Employees’ Coverage

• Members will continue to need authorization for the medications listed below. These already required authorization when covered under the member’s medical benefits.
• Members who wish to switch to an alternate site of service can work with their physicians and clinicians to transfer their care to a home infusion therapy provider in our network, if it’s clinically appropriate and with an approved authorization. We’re working with our network home infusion therapy providers to make this a smooth transition for members.

The Voluntary Site of Care Program will apply to all medical plans except for the following plan types:

1. - Federal Employee Program
2. - Indemnity
3. - Managed Blue for Seniors
4. - Medex^®´
5. - Medicare Advantage

If you have any questions, contact your account executive.

Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective January 1, 2022

Beginning January 1, 2022, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ * plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

• No longer be covered (exceptions may be granted)
• Switch tiers
• Have new quantity or dosing limits
• Require prior authorization and/or step therapy

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

Medications No Longer Covered Starting January 1, 2022

After carefully reviewing each medication’s cost and its clinically appropriate covered alternatives, we’ve removed the medications listed below from our formulary. However, a doctor may request an exception if the medication prescribed is medically necessary. If the exception is approved, the member will pay the highest-tier cost.

*This medication also has prior authorization and/or step therapy requirements.

Medications Switching Tiers

When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a lower or higher tier under certain pharmacy plans, and what members pay for the following medications may increase or decrease.

* This medication also has prior authorization and/or step therapy requirements.

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.
6. This medication was previously covered at Tier 6.
7. This medication was previously non-covered.

Medications with New Quality Care Dosing Limits

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, some of the medications listed below now require Quality Care Dosing (QCD), while the QCD limit has changed for others.

Medical Policy Updates

Medical policies are evidence-based documents that Blue Cross develops to define the technologies, procedures, and treatments that are considered medically necessary, not medically necessary, and investigational. We use Pharmacy medical policies to describe how we cover certain medications. We’re updating the policies listed below. These changes include:

• Step therapy policy changes that apply to members newly prescribed the medications listed within the pharmacy medical policies. With step therapy, the member may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. The doctor can request an exception if needed.
• Prior authorization for members newly prescribed Alunbrig.

Looking for More Information?

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

Questions?

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

Health Plan Updates for 2022

Effective January 1, 2022, and upon renewal, we’re making changes to our health plans to ensure that we continue to meet the ongoing requirements of health care reform, while providing the high-quality, affordable coverage you and your employees expect from Blue Cross.

In 2022, we’ll offer:

• - BlueFit: the next generation, proactive health plan
• - Telehealth updates
• - Solutions that create value for our members
  • Value care options
  • 90-day retail medication dispensing
  • $0 copay medications
• - Solutions supporting health and wellness
  • Home fitness equipment reimbursement
  • Optional Mind & Body Program
• - Solutions to address affordability
  • New merged-market plan designs
  • Plans designed for lower premiums

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

Accounts with 50 or Fewer Enrolled

Accounts with 51–99 Enrolled

Accounts with 100 or More Enrolled

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

Questions?

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

Prior Authorization Change for Outpatient Services for EPO and PPO Plan Members

We originally notified you in November 2021 of this upcoming change, and then we updated you in December 2021 that we would be delaying the effective date due to a DOI bulletin. Today, April 15th, we are notifying you that this prior authorization change will take effect on June 1, 2022.

We're adding prior authorization requirements for certain outpatient services for EPO and PPO plan members, effective June 1, 2022. This requirement helps ensure members receiving safe, effective, and medically necessary services. Services include, but are not limited to:*

• Continuous glucose monitors
• Cosmetic procedures
• Nasal sprays or injections to treat depression
• Spine surgeries (except for Medicare PPO plan members)
• Stem cell transplants

Providers-both in network and out of network**-will need to request authorization for members receiving ongoing treatment, and for members who begin treatment on or after the effective date. We'll review requests against our necessity criteria.

If you have questions, please contact your account executive.

*Members should check their plan details for the full list of services, or call Member Service.
**This only applies to in-network providers of Medicare Advantage PPO plan members.

Expanded Coverage for Treatment of PANDA/PANS

As of January 1, 2022, Blue Cross Blue Shield of Massachusetts will expand coverage for the treatment of pediatric autoimmune neuropsychiatric disorders and pediatric acute-onset neuropsychiatric syndromes (PANDAS/PANS). This includes, but it is not limited to, intravenous immunoglobulin (IVIG) therapy.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndromes (PANS) can be triggered by a strep infection and occur suddenly in previously healthy children ages of 2-12. Symptoms can include obsessions and compulsions, extreme anxiety, trouble sleeping, difficulty with school work, bodily tics, and other ailments.

This treatment coverage applies to all members except Medicare Advantage and Federal Employee Program members.