Pharmacy Benefit Updates

Some Previously Announced Medical Policy Changes for the Blue Cross Blue Shield of Massachusetts Formulary Are Being Delayed

The medical policy changes below, which were previously announced to be effective January 1, 2024, are being delayed to March 1, 2024.

Questions?

If you have any questions, call Team Blue at the Member Service number on your ID card.

UPDATE - Effective January 1, 2024, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

Effective January 1, 2024, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´1 plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

• No longer be covered (exceptions may be granted)
• Have new quantity or dosing limits
• Be required to be filled at an in-network specialty pharmacy
• Require prior authorization and/or step therapy
• No longer be covered under the medical benefit and will only be covered under the pharmacy benefit

We’re also making medical policy changes, effective January 1, 2024.

^{1. This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.}

Medications No Longer Covered Starting January 1, 2024

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, you’ll pay the highest-tier cost.

^{*If you’re currently using these medications, you’ll be allowed to continue and will pay your highest copay amount.}

Medications with New Quality Care Dosing (QCD) Limit

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, the medication listed below now requires QCD.

Medications Required to Be Filled at an In-Network Specialty Pharmacy

Effective January 1, 2024, the following medications will only be covered when filled at an in-network specialty pharmacy:

Prior Authorization Now Required for Briumvi and Ocrevus

Effective January 1, 2024, prior authorization will be required for new and existing prescriptions of Briumvi and Ocrevus in order to be covered by your plan.

The medications will be covered under our medical benefit when administered at a health care provider’s office, by a home health care provider, by a home infusion therapy provider, or in an outpatient hospital and dialysis setting. They’ll be covered under our pharmacy benefit when they’re filled at a specialty pharmacy.

Prior authorization won’t be required when Briumvi and Ocrevus are administered in inpatient, surgical day care, urgent care centers or emergency department settings.

Coverage Changes for Certain Medications Being Removed from Our Medical Benefit

Effective January 1, 2024, the following specialty medications will no longer be covered by our medical benefit. They’ll only be covered under our pharmacy benefit when filled at an in-network specialty pharmacy. Prior authorization is still required for these medications. This change will apply to all medical plans, except Medicare Advantage, Medical Supplemental plans, and Federal Employee Program plans.

• Simponi Aria
• Stelara

If you’re currently filling these specialty medications at an in-network specialty pharmacy under our pharmacy benefit, you won’t experience a break in coverage. If you’re currently filling these medications under our medical benefit and have pharmacy coverage with Blue Cross Blue Shield of Massachusetts, you’ll receive a detailed letter about the coverage change, along with next steps. If you don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts, we’ll also send you a letter about the change, with additional information about contacting your prescription plan to find out if you’re covered for these medications.

Medical Policy Updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization requirements for specific medications to ensure your doctor has determined that a medication is necessary to treat you, 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, call Team Blue at the Member Service number on the front of your ID card.

Effective January 1, 2024, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

Effective January 1, 2024, 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 and/or step therapy
• No longer be covered under the medical benefit and will only be covered under the pharmacy benefit

We’re also making medical policy changes, effective January 1, 2024.

Complete details about these changes will be available by October 31, 2023. Check back at that time.

Questions?
If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

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

UPDATE - Effective July 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

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

• No longer be covered (exceptions may be granted)
• Have new quantity or dosing limits
• Switch tiers
• Require prior authorization and/or step therapy
• No longer be covered under the medical benefit and will only be covered under the pharmacy benefit

We’re also making medical policy changes, effective July 1, 2023.

^{1. This doesn’t include Medex®´ 2 plans with Blue MedicareRx (PDP) prescription drug coverage.}

Medications No Longer Covered Starting July 1, 2023

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

Medications with New Quality Care Dosing (QCD) Limit

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, the medication listed below now requires Quality Care Dosing (QCD).

Medications Switching Tiers

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

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

a. This medication was previously covered at Tier 3.
b. This medication was previously covered at Tier 4.
c. This medication was previously covered at Tier 5.
d. This medication was previously covered at Tier 6.

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

Effective July 1, 2023, coverage for the following specialty medications will move out of our medical benefit and only be included under our pharmacy benefit. These medications will also only be covered when filled at an in-network specialty pharmacy. This change will apply to all medical plans, except Medicare Advantage, Medical Supplemental plans, and Federal Employee Program plans.

• Ilumya
• Skyrizi

If you’re currently filling these specialty medications at an in-network specialty pharmacy under your pharmacy benefit, you won’t experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit. If you’re currently filling these medications under your medical benefit and have pharmacy coverage with Blue Cross Blue Shield of Massachusetts, you’ll receive a detailed letter about the coverage change, along with next steps. If you don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts, we’ll also send you a letter about the change, with additional information about contacting your prescription plan to find out if you’re covered for these medications.

Medical Policy Updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization requirements for specific medications to ensure your doctor has determined that a medication is necessary to treat you, 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, call Team Blue at the Member Service number on the front of your ID card.

Quality Care Dosing Limits Have Increased for Select Medications

To give doctors greater flexibility when prescribing certain controlled substances, we’ve doubled the quality care dosing limit for the medications listed below. The change took effect on April 12, 2023, and applies to members whose plans have pharmacy coverage through Blue Cross Blue Shield of Massachusetts and use the Blue Cross formulary.

The following medications increased coverage to 60 units for a 30-day supply:

• AMPHETAMINE/DEXTROAMPHETAMINE CAP 5MG ER
• AMPHETAMINE/DEXTROAMPHETAMINE CAP 10MG ER
• AMPHETAMINE/DEXTROAMPHETAMINE CAP 15MG ER
• AMPHETAMINE/DEXTROAMPHETAMINE CAP 25MG ER
• METHYLPHENIDATE TAB 18MG ER
• METHYLPHENIDATE TAB 27MG ER
• METHYLPHENIDATE TAB 54MG ER

The following medications increased coverage to 120 units for a 30-day supply:

• AMPHETAMINE/DEXTROAMPHETAMINE CAP 20MG ER
• AMPHETAMINE/DEXTROAMPHETAMINE CAP 30MG ER
• METHYLPHENIDATE TAB 36MG ER

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

Effective July 1, 2023, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

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

• No longer be covered (exceptions may be granted)
• Be excluded from coverage (exceptions won’t be granted)
• Switch tiers
• Require prior authorization and/or step therapy
• No longer be covered under the medical benefit and will only be covered under the pharmacy benefit

We’re also making medical policy changes, effective July 1, 2023.

Complete details about these changes will be available by May 31, 2023. Check back at that time.

Questions?

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

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

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, you’ll pay the highest-tier cost.

1. This medication also has prior authorization and/or step therapy requirements.
2. If you currently use this medication, you’ll continue to be covered until your prior authorization expires.
3. If you use this medication, you’ll 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. You’ll 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 you if you’ll 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 you pay for the following medications may increase or decrease. This isn’t a complete list of medications switching tiers, and we’ll contact you if you’ll 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 policies is newly prescribed for you. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization requirements for specific medications to ensure your doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for More Information?

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

Questions?

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

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, you’ll pay the highest-tier cost.

1. This medication also has prior authorization and/or step therapy requirements.
2. If you currently use this medication, you’ll continue to be covered until your prior authorization expires.
3. If you use this medication, you’ll 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. You’ll 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 you if you’ll 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 you pay for the following medications may increase or decrease. This isn’t a complete list of medications switching tiers, and we’ll contact you if you’ll 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 policies is newly prescribed for you. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization requirements for specific medications to ensure your doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for More Information?

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

Questions?

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

Encompass Fertility^™ Has Joined Our Specialty Pharmacy Network for Fertility Medications

Effective July 19, 2022, Encompass Fertility has joined our specialty pharmacy network for fertility medications. They have access to all our covered fertility medications, and they can fill and ship medications in all 50 states.

This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF). For more information about specialty fertility medications, use our Medication Lookup tool.

Questions?

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

Metro Drugs Is Leaving Our Specialty Pharmacy Network for Fertility Medications

Effective May 1, 2022, Metro Drugs, a fertility medication pharmacy, will be leaving our specialty pharmacy network. If you’re taking fertility medications and fill your prescriptions through Metro Drugs, you’ll be able to complete your current course of treatment with Metro Drugs, but treatments starting after May 1, 2022 will need to be filled through Freedom Fertility Pharmacy, or Village Fertility Pharmacy in order to be covered. If you’re currently using Metro Drugs, you’ll receive a letter from us about next steps.

This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF). For more information about specialty fertility medications, use our Medication Lookup tool.

Questions?

If you have any questions, call Team Blue at the Member Service number on the front of your ID card.

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 you 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, call Team Blue at the Member Service number on the front of your ID card.

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, you'll 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 you 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 when the medication within the pharmacy medical policies is newly prescribed for you. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization. This applies if you are 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 call Member Service at the number on the front of your ID card.

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, you’ll pay the highest-tier cost.

**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.

Medications Requiring Prior Authorization

For certain medications, your doctor must first obtain approval before we cover them. The following medications now require 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, call Team Blue at the Member Service number on your ID card.

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

Effective July 1, 2021, pharmacists filling an opioid prescription will be alerted if you 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 an opioid prescription, they’ll receive a real-time alert if your 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, your 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, call Team Blue at the Member Service number on your ID card.

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

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. This change will apply to all medical plans, except Managed Blue for Seniors, group Medicare Advantage, group Medex®´, and Federal Employee Program plans.

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. Group Medex plans with a three-tier pharmacy benefit will include coverage for these medications under both the medical and pharmacy benefit. If you don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts, refer to your pharmacy plan benefit materials for coverage details on these medications.

If affected, we’ll contact you about this change and help you transition your prescription to support uninterrupted coverage.

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

Questions?

For more information, call Team Blue at the Member Service number on your ID card.

*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.

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 and will require prior authorization. These medications will no longer be included in our pharmacy benefit.

The Quality Care Cancer Program, which launches July 1, 2021, is administered by AIM Specialty Health^®´´ (AIM), an independent company. You can 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. If you’re a member of an affected plan and are currently filling these medications under the pharmacy benefit, you’ll be able to complete your treatment course without interruption.

If your plan includes medical benefits from Blue Cross and pharmacy benefits from another carrier, you can receive coverage for these medications from us under your medical benefit. To see if you’re also covered by your pharmacy benefits from another carrier, please refer to your pharmacy plan benefit materials.

Questions?

If you have any questions, call Team Blue at the Member Service number on your ID card.

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

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 you and your prescriber if this change applies to you.

If you have any questions, please call Member Service on the front of your ID card.

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

We previously announced changes to the Blue Cross Blue Shield of Massachusetts formulary (list of covered medications) that are going into effect January 1, 2021. Since then, we’ve made updates to these formulary changes. The updates are as follows:

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:

Medications Switching Tiers

Medications in the high-triglyceride treatment class listed below will move to a higher cost tier, so what you pay for the following medications may increase.

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:

If you have any questions, please call Member Service at the number on the front of your ID card.

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 MedicareRx^TM (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, you’ll pay the highest-tier cost.

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. You’ll 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.

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 you pay for the following medications may increase or decrease.

a. This medication was previously covered at Tier 2 and requires step therapy.
b. This medication was previously covered at Tier 1.
c. 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.

Medications Requiring Prior Authorization

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

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 call Member Service at the number on the front of your ID card.

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.

If you’re currently taking Remicade, you should have received a letter from us with the details of this coverage change, encouraging you to talk to your doctor about switching to Inflectra before your prior authorization for Remicade expires. If your doctor determines Remicade is medically necessary, your doctor can request an exception for coverage. If the exception is approved, you'll pay the highest-tier cost when filling the medication under the pharmacy benefit. If filling the medication under the medical benefit, you'll pay your usual out-of-pocket costs.

Prior authorization is required for Inflectra and Remicade prescriptions.

Questions?

If you have any questions, call the Member Service number on the front of your ID card.

Sam’s Club Will Remain in Our Pharmacy Network

We’re pleased to announce that Sam’s Club will remain in our pharmacy network. You can continue to fill prescriptions at Sam’s Club pharmacy locations without interruption to your coverage.

If you recently filled a prescription at Sam’s Club, and received letters explaining that the pharmacy would be leaving the network, you can disregard these letters. New letters will be sent to you, confirming that the pharmacy will stay in-network.

Questions?

If you have any questions, please call Member Service at the number on your ID card.

Changes to Our Specialty Pharmacy Network for Fertility Medications

Beginning August 31, 2020, AcariaHealth™ Fertility will no longer participate in 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 call Member Service at the number on the front of your ID card.

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 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™ (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, you’ll pay the highest-tier cost.

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, you 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.

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.

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

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.

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.

Looking for More Information?

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

Questions?

If you have any questions, please call Member Service at the number on the front of your ID card.

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 call Member Service at the number on the front of your ID card.

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 call Member Service at the number on the front of your ID card.

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 at bluecrossma.org/disclaimer/plan-updates/pharmacy-benefit-updates. If you have any questions, please call Member Service at the number on the front of your ID card.

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, your doctor will be required to obtain Prior Authorization from us before additional medication can be covered and dispensed.

If you have any questions, please call Member Service at the number on the front of your ID card.

July 1st Formulary Changes Temporarily Delayed

In a recent Direct to You newsletter we notified you of upcoming formulary (list of covered medications) changes for July 1st that affected medical plans with pharmacy benefits as well as Medex^{® ́} plans with a three-tier pharmacy benefit. These changes have been temporarily delayed.

If you have any questions, please call Member Service at the number on the front of your ID card.

May 1st Formulary Changes Temporarily Delayed

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

If you have any questions, please call Member Service at the number on the front of your ID card.

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, your doctor may request an exception if these medications are medically necessary. If the exception is approved, you’ll pay the highest-tier cost.

Questions?

If you have any questions, please call Member Service at the number on the front of your ID card.

Changes to our speciality pharmacy network

Beginning March 31, 2020, BriovaRx^®'' will no longer participate in our specialty pharmacy network. This change applies to the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF). This doesn't affect members who have Medicare Advantage with a Part D prescription drug plan; they can continue to use BriovaRx without interruption. 

Unless you have Medicare Advantage with a Part D plan, you’ll 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 call Member Service at the number on the front of your ID card.

Changes to your prescription coverage

Beginning January 1, 2020, we’re updating our list of covered medications for medical plans with pharmacy benefits, as well as Medex^®' plans with a three-tier pharmacy benefit. As part of these updates, certain medications may:

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

Medications no longer covered in 2020

After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the table below from our covered medications list. However, your doctor may request an exception if these medications are medically necessary. If the exception is approved, you’ll pay the highest-tier cost.

*If you currently take Strattera, your medication will continue to be covered until the current authorization expires. However, you’ll pay the highest-tier cost.

Medications excluded from coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2020. You’ll 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
• Pliaglis²
• Prilocaine 7%/Tetracaine 7%²
• Sil-k 2” X 5” Pad³

1. Over-the-counter alternatives that don’t require a prescription are available for this medication.
2. This medication isn’t available over-the-counter and is only available for medical professional use.
3. Coverage for bandages isn’t included under our pharmacy benefit.
4. This medication is available over-the-counter without a prescription.

Medications switching tiers

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

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

Medications with new quality care dosing limits

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, we’re reducing Quality Care Dosing Limits for the following medications:

Expanded access to certain cholesterol medications

In 2020, you’ll 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.

Coverage of Opioid Alternatives, and Change in Massachusetts’ "Partial Fill" Law

For members who prefer not to use opioids, a class of medication that includes OxyContin and Vicodin and is sometimes prescribed by doctors to treat pain, our standard plans cover a wide range of alternative treatment options, including more than 500 non-opiate medications (nonsteroidal anti-inflammatory drugs, and topical analgesics).*

We also cover several specialty services, combining therapies to offer individualized treatment for pain management, including:

• physical and occupational therapy (PT/OT)
• chiropractic treatment
• pain medicine specialists
• transcutaneous electrical nerve stimulation (TENS) units
• acupuncture (beginning January 1, 2020 for new or renewed plans)

We’ll be adding an Alternatives to Opioids section to the Medication Lookup tool by the end of December. That’s where you’ll find an Alternatives to Opioids fact sheet and medication list.

Also, due to a recent change in Massachusetts’ “partial fill” law, there’s no extra charge if you choose to partially fill your narcotic or opioid prescription. You won’t be charged an additional copay if you fill the remainder of your prescription at the same pharmacy within 30 days.

*For more information about coverage for non-opiate medications, members should check their pharmacy benefit materials. For covered pain management services, they should check their medical benefit materials.

National Prescription Drug Take Back Day is October 26, 2019

Medications don’t last forever. Over time, their chemical properties change, making them less potent—and even dangerous. Take the time to go through your medicine cabinets and check for any expired or unwanted medications—this includes everything from aspirin to prescription medications.

The U.S. Drug Enforcement Administration’s next National Prescription Drug Take Back Day is Saturday, October 26, 2019, from 10:00 a.m. to 2:00 p.m. Anyone can take part by bringing expired or unused medications to a local disposal location.

Use the U.S. Drug Enforcement Administration's search tool to find a collection site near you.

Changes to our speciality pharmacy network and medication list

Beginning July 1, 2019, we’ll make the following changes to our retail specialty pharmacy network and to the medications these pharmacies can fill.

AllianceRx Walgreens Prime will leave our retail specialty pharmacy fertility network

AllianceRx Walgreens Prime will no longer be in our retail specialty pharmacy fertility network. If you’re receiving specialty fertility medications through AllianceRx Walgreens Prime, you can complete the medications for your current cycle, but we won’t cover prescriptions filled at AllianceRx Walgreens Prime on or after July 1, 2019. If this change impacts you, we’ll reach out to you directly.

BriovaRx^® will leave our fertility network, but remain in our specialty network

BriovaRx will no longer be in our fertility network, but will continue to fill other prescriptions in our Specialty Network. If you’re receiving fertility medications through BriovaRx, you can complete the medications for your current cycle, but we won’t cover fertility prescriptions filled at BriovaRx on or after July 1, 2019. If this change impacts you, we’ll reach out to you directly.

Updates to our specialty pharmacy medication list

Beginning July 1, 2019, we’ll cover additional medications and new-to-market medications in our specialty pharmacy network.

Medications now available through our specialty pharmacy network:

• Cinryze
• Haegarda
• Berinert
• Kalbitor
• Ruconest

New-to-market medications:

Questions?

If you have any questions, please call Member Service at the number on the front of your ID card.

Introducing our new Medication Lookup Tool

With our new and improved Medication Lookup tool, you can easily determine which medications are covered by your plan. You’ll also find covered alternatives to non-covered medications, as well as which medications have additional requirements before being prescribed. You can use the tool to:

• Search for any medication
• View medications by strength
• See medications by how they’re dispensed, such as pills, liquids, and injections
• Learn which medications have additional requirements, such as Prior Authorization, Step Therapy, and Quality Care Dosing
• See covered alternatives for non-covered medications

View medications by tier*

To use the tool, go to Medication Lookup tool.

Questions?

If you have any questions, please call Member Service at the number on the front of your ID card.

*A medication’s tier is based on your plan design. Knowing how many tiers your plan has can help you understand your out-of-pocket costs. Instructions to find which plan you have are included within the tool.

Coming in July 2019: 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. Your doctor or prescriber may request a coverage exception if the medication is medically necessary. If the request is approved, you’ll pay the highest-tier cost for the medication.

*If you’re currently prescribed to Procrit, you may continue to fill your prescription under your existing prior authorization. However, you’ll pay more 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 you more.

^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.