UPDATE - Effective January 1, 2025, Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

Effective January 1, 2025, 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)
• Be excluded from coverage (exceptions won’t 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 January 1, 2025.

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

Medications no longer covered starting January 1, 2025

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. We’ll continue to cover this medication for members already taking the medication. However, members will pay their plan’s highest-tier cost.}

Medications excluded from coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2025. 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.

Medications with new quality care dosing (QCD) limits

After carefully reviewing each medication’s cost, its clinically appropriate covered alternatives, and the FDA-approved label dosage guidelines, we’re changing QCD limits to the medication(s) listed below on our formulary. However, a doctor may request a QCD exception if the quantity being requested for coverage is medically necessary.

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. 

^{2. This medication also requires prior authorization.}

1. This medication was previously non-covered.
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.

Medications requiring prior authorization

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

^{3. Members currently filling prescriptions for this medication won’t need prior authorization.}

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, 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.

UPDATE - Effective January 1, 2025, changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2025, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

The CVS Weight Management Program^TM Aims to Turn Meaningful Weight Loss into a Healthier Bottom Line

Starting January 1, 2025 upon plan renewal, self-insured accounts with 100+ members can add the CVS Weight Management Program to their plan under the pharmacy benefit. While we offer a few weight-management solutions, this unique program takes a holistic, high-touch approach to weight management. It’s designed to help members taking weight-management medications achieve long-term success and reduce co-morbid conditions.

We’re offering this program to help you manage the high costs associated with increased demand for weight-management medications. Through appropriate clinical support and lifestyle change management on an ongoing basis, you can be assured that members will have dedicated provider oversight and other resources aimed at achieving meaningful weight-loss results.

Members taking a weight-management medication are required to participate in the program, or they’ll be responsible for the full out-of-pocket cost of their medication.¹

Program features

A dedicated care team
Registered dietitians, endocrinologists, and other providers offer one-on-one clinical support.

Custom nutrition plans
A registered dietitian will create a personalized plan based on dietary requirements and cultural needs.

The Health Optimizer^TM app
Members can log biometrics, track their medications, set up virtual appointments, and more.

A smart body-weight scale
All program participants get a scale, at no cost to them, that connects to the app to help them track their progress.

To learn more, contact your account executive.

1. Members who have a prior authorization on file and are taking a weight-management medication must enroll in, engage in, and meet the requirements of this program to get their medication at their plan cost-share.

Effective January 1, 2025, Changes to the Blue Cross Blue Shield of Massachusetts Formulary and Medical Policy Updates

Effective January 1, 2025, 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)
• 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 January 1, 2025.

Complete details about these changes will be available by October 25, 2024 in the What’s New section.

If you have any questions, contact your account executive.

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

Effective January 1, 2025, Changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2025, CVS Caremark^®´, 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by October 25, 2024 in the What’s New section.

UPDATE - Effective October 1, 2024, Changes to the Standard Control with Advanced Control Specialty Formulary

Effective October 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

Effective October 1, 2024, Changes to the Standard Control with Advanced Control Specialty Formulary

Effective October 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by August 22, 2024 in the What’s New section.

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

Effective July 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)
• Switch tiers
• Require prior authorization and/or step therapy

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

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

Medications No Longer Covered Starting July 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, the member will pay the highest-tier cost.

^{*Members currently taking any of these medications will be allowed coverage so they can continue using them. They’ll pay the highest copay amount at checkout.}

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 non-covered.
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.

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, 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 that 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.

UPDATE - Effective July 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective July 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

Little Eyes, Big Benefits

Eye care is so important — especially for kids. Correcting vision problems at an early age can have a lasting, positive impact, such as improving the ability to learn. We want to make sure kids get the right care at the right time by offering enhanced vision coverage, at no additional cost, for kids under 19 who are enrolled in select Blue 20/20 plans.

The enhanced vision coverage for kids under 19 will be effective July 1, 2024, and will apply to Exam Plus vision plans only.¹ Enhanced vision coverage includes:

• Two fully covered eye exams at $0-copay per benefit frequency
• One pair of replacement lenses (subject to a prescription change) per benefit frequency
• Fully covered blue-light prescription lenses treatment
• Fully covered standard polycarbonate lenses
• 35% off non-prescription, blue-light glasses

To learn more, download the fact sheet.

Questions?

If you have any questions, contact your account executive.

^{1. Applicable plans include Exam Plus plans. Does not apply to Materials Only and Exam Only vision plans. Enhanced coverage will be applied automatically to eligible plans on July 1, 2024.
*We partner with EyeMed®´ Vision Care, an independent vision benefits company, to offer our comprehensive vision plans.}

Effective July 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective July 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by May 28, 2024 in the What’s New section.

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

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

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

Complete details about these changes will be available by May 28, 2024 in the What’s New section.

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

UPDATE - Effective April 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective April 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

UPDATE: Effective April 1, 2024, Upcoming Medical Policy Change for the Blue Cross Blue Shield of Massachusetts Formulary

Effective April 1, 2024, we're updating the following medical policy to provide coverage for more affordable medication options for our members. This change affects our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´1 plans with a three-tier pharmacy benefit.

If you have any questions, contact your account executive.

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

Effective April 1, 2024, Upcoming Medical Policy Change for the Blue Cross Blue Shield of Massachusetts Formulary

Effective April 1, 2024, we're updating a medical policy for our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^{® ́1} plans with a three- tier pharmacy benefit.

Complete details about these changes will be available by January 4, 2024 in the What’s New section.

If you have any questions, contact your account executive.

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

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.

If you have any questions, contact your account executive.

Effective April 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective April 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by February 21, 2024 in the What’s New section.

A REWARDING NEW WAY TO HELP MEMBERS STAY ADHERENT

Starting January 1, 2024, we’re introducing a new program that rewards members for filling certain medications* on time, by lowering their out-of-pocket costs. The program is intended for eligible members who are taking medications that treat chronic conditions, such as diabetes and cardiovascular disease.

Enrollment is required to participate in the program.** Sempre Health, an independent company that manages the program, will reach out to eligible members to get them to enroll. Once enrolled, members will have the opportunity to purchase their medications at a reduced cost. The more adherent they are, the more they can save.

If you’re a fully insured account with 51+ employees, or a Blue Funding self-insured account with 51-99 employees, the program will be included in your plan. If you’re a self-insured account with 100+ employees, you can opt in at no additional cost. The program can’t be paired with an HSA-compliant or Medicare plan.

If you have any questions, contact your account executive.

^{*Eligible medications as of January 1, 2024 include Eliquis®´, Mounjaro®´, Toujeo®´, Trulicity®´, and Xarelto. Medications in the program are subject to change.
**Participation in the program is optional.}

Lowering Our Member’s Pharmacy Costs

We’re pleased to introduce Cost Saver^TM, a new feature that automatically gives our pharmacy members the lowest possible out-of-pocket price on commonly prescribed generic, non-specialty medications. Cost Saver lowers members’ pharmacy costs, eliminates the need to shop around for the best price, and encourages better medication adherence.

Cost Saver is powered by GoodRx, an independent company that tracks medication prices at pharmacies across the United States to provide discounts on prescriptions. The program will be included in all of our commercial plans, effective November 1, 2023, for fully insured accounts and January 1, 2024, for self-insured accounts.

A seamless member experience

Cost Saver finds pharmacy members the lowest possible price during the claim adjudication process, so they don’t need to do anything. Here’s how it works:

1. The member’s provider sends the prescription to the pharmacy.
2. While the pharmacy processes the claim, Cost Saver automatically identifies the lowest cost option for the medication.
3. The member presents their Blue Cross ID card when they pick up their prescription. They don’t need to show any additional discount card.
4. The member pays the lowest possible out-of-pocket cost at that time, which may be the GoodRx price.
5. The member’s payment is automatically applied to their deductible and/or out-of-pocket maximum.

Questions?

If you have any questions, contact your account executive.

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, the member will pay the highest-tier cost.

^{*Members currently using these medications will be allowed to continue and will pay their highest copay amount.}

Medications with New Quality Care Dosing (QCD) Limit

After carefully reviewing each medication’s cost, its clinically appropriate covered alternatives, and the FDA-approved label dosage guidelines, we’re adding QCD limits to the medication(s) listed below on our formulary. However, a doctor may request a QCD exception if the quantity being requested for coverage is medically necessary.

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

Members who are currently filling these medications will receive a detailed letter about the coverage change, along with next steps. Members who are currently filling these specialty medications at an in-network specialty pharmacy under our pharmacy benefit won’t experience a break in coverage. Members who don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts will also receive a letter about the change, with additional information about contacting their prescription plan to find out if they’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, 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.

UPDATE - Effective January 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

Health plan updates for 2024

Choosing the right health plan is essential to attracting and retaining top talent. 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 and your employees expect from Blue Cross.

In 2024, we’ll offer:

• New plans and plan enhancements to expand network access, virtual care options, and riders that address cost share options
• Sempre Health offers discounts to eligible members taking select medications to remain adherent when their out-of-pocket costs are reduced. Members will receive refill reminders and discounted cost information prior to picking up their medication.
• Lifestyle Spending Accounts (LSAs) are funded by an employer through payroll and fully customizable to provide flexibility and allows employees to spend benefit dollars on what matters most to them, across the wide spectrum of physical, emotional, and financial well-being. For more details on these new offerings, view the 2024 Brochures.
• Accounts with 50 or Fewer Enrolled
• Accounts with 51–99 Enrolled
• Accounts with 100 or More Enrolled

Questions?

If you have any questions, contact your account executive.

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 25, 2023 in the What’s New section. If you have any questions, contact your account executive.

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

Effective January 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by October 25, 2023 in the What’s New section.

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.

If you have any questions, contact your account executive.

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, the member will pay the highest-tier cost.

^{*Members currently using these medications will be allowed to continue and will pay their highest copay amount.}

Medications with New Quality Care Dosing (QCD) Limit

After carefully reviewing each medication’s cost, its clinically appropriate covered alternatives, and the FDA-approved label dosage guidelines, we’re adding QCD limits to the medication(s) listed below on our formulary. However, a doctor may request a QCD exception if the quantity being requested for coverage is medically necessary.

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

Members who are currently filling these medications will receive a detailed letter about the coverage change, along with next steps. Members who are currently filling these specialty medications at an in-network specialty pharmacy under our pharmacy benefit won’t experience a break in coverage. Members who don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts will also receive a letter about the change, with additional information about contacting their prescription plan to find out if they’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, 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.

UPDATE - Effective January 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

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 25, 2023 in the What’s New section. If you have any questions, contact your account executive.

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

Effective January 1, 2024, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective January 1, 2024, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by October 25, 2023 in the What’s New section.

UPDATE - Effective October 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective October 1, 2023, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

Effective October 1, 2023, Even More Access to Oral Health Care

Our Dental Blue^® benefits continue to evolve to meet the needs of our members by offering more affordable oral care. Two important benefit enhancements will be effective on 10/1/2023 for new accounts, and existing accounts upon renewal:

Expansion to Enhanced Dental Benefits:

• Our Enhanced Dental Benefits provide additional, specific support, including full coverage for preventive and periodontal services, to members with qualifying medical conditions that may require increased oral care. Now, we're expanding these conditions to include intellectual and/or developmental disabilities and mental health conditions.

To learn more, download the fact sheet.

100% Coverage for Kids Under 13:

• We’ll provide 100% coverage for kids under the age of 13, with no cost and no deductible for covered dental services. We’re committed to making dental care for your employees and their kids more accessible and affordable, so their oral health starts off on the right track. This coverage applies only to large group (51+) dental plans.

To learn more, download the fact sheet.

Questions?

If you have any questions, contact your account executive.

Effective October 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective October 1, 2023, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by August 24, 2023 in the What’s New section.

UPDATE - Effective July 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective July 1, 2023, CVS Caremark^®´, 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

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, the member will pay the highest-tier cost.

Medications with New Quality Care Dosing (QCD) Limit

After carefully reviewing each medication’s cost, its clinically appropriate covered alternatives, and the FDA-approved label dosage guidelines, we’re adding QCD limits to the medication(s) listed below on our formulary. However, a doctor may request a QCD exception if the quantity being requested for coverage is medically necessary.

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 members pay for the following medications may decrease.

2. 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.

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

Members who are currently filling these specialty medications at an in-network specialty pharmacy under their pharmacy benefit won’t experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit. Members who are currently filling these medications under their medical benefit and have pharmacy coverage with Blue Cross Blue Shield of Massachusetts will receive a detailed letter about the coverage change, along with next steps. Members who don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts will also receive a letter about the change, with additional information about contacting their prescription plan to find out if they’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, 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.

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 plans that 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, contact your account executive.

Update: New Neonatal Intensive Care Unit (NICU) Program Begins November 1, 2023

Update posted August 4, 2023: This program will begin on November 1, 2023.

Starting November 1, 2023, we’ll be working with ProgenyHealth^®´, an independent health care company dedicated to maternity and infant health, to provide Neonatal Intensive Care Unit (NICU) utilization management and care management services for eligible commercial members.

ProgenyHealth will manage the NICU level-of-care review process and provide comprehensive care management services to babies cared for in the NICU or special care nursery, and for the first year of their life. Babies born prior to November 1, 2023, who were cared for in the NICU, may have their care managed by ProgenyHealth, depending on the level of care. We’ll manage the transition to this program.

Benefits of the program include:

• A dedicated team of specialists from ProgenyHealth that works with the infant’s care team to improve outcomes, and evaluate external issues that may affect the baby’s health.
• Additional clinical support for the baby’s family that supports a safe discharge.
• A dedicated care manager who provides support and education.
• An on-call staff member who’s available 24/7.

Additional prior authorizations won’t be required as inpatient NICU services already require authorizations.

If you have any questions, contact your account executive.

Introducing Blue 20/20 PLUS: Enhanced Vision Care

Starting July 1, 2023, with the new Blue 20/20 PLUS enhanced coverage (part of Blue 20/20’s portfolio expansion), members can get greater savings on their vision care. Members receiving care from PLUS providers, who are already a part of our Blue 20/20 provider networks, will get the following enhanced benefits:

• $0 exam copay
• Additional $50 frame allowance, with no brand restrictions

In addition, these benefits can be combined with other offers and discounts to provide even greater savings and a seamless member experience.

Learn more about Blue 20/20 PLUS here.

Questions?

If you have any questions, contact your account executive.

Preventive Care Mammograms for Adult Commercial Members at Any Age

All HMO, PPO (including POS and EPO), and Indemnity plan members are covered for at least one preventive-care mammogram screening per year, without age restriction, when ordered by a provider. This benefit is $0 for members for in-network services.

Diagnostic imaging — as opposed to imaging for preventive-care purposes — is subject to deductible, copayment, and/or co-insurance.

Members should speak to their doctor about the mammogram schedule that’s right for them.

Application of this benefit and the associated cost share continues to be aligned with other plan preventive health screening services. The benefit and its cost-share are also in accordance with National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, and they comply with the Patient Protection and Affordable Care Act.

If you have any questions, contact your account executive.

Effective July 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective July 1, 2023, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by May 24, 2023 in the What’s New section.

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 24, 2023 in the What’s New section.

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

UPDATE - Effective April 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective April 1, 2023, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary (SC-ACSF). 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
• Be added to the list of covered medications
• Be designated as preferred

To see the SC-ACSF changes and current medication lists, go to the Medication Lookup tool.

Change in Prior Authorization Requirements for Certain Musculoskeletal Services

As shared in Q4 2022, we're updating our prior authorization requirements for certain musculoskeletal (MSK) services for all HMO and PPO plan members*. These changes will go into effect on April 1, 2023. We'll review requests according to evidence-based medical necessity criteria to help ensure that members are receiving safe, effective, and medically necessary MSK services. Throughout their MSK treatment, appropriate members will be offered support from our Care Managers.

In- and out-of-network providers will need to submit prior authorization requests for members receiving ongoing treatments for specified joint, spine, and pain management, and for members who begin treatment on or after April 1, 2023.

If you have questions, contact your account executive.

* For the full list of services, members should check their plan details or call Member Service.

Mental Health Treatment: Prior Authorization Changes

We’ve removed prior authorization requirements for Intensive Community-Based Treatment (ICBAT), Community-Based Acute Treatment (CBAT), and inpatient psychiatric treatment, consistent with the Massachusetts Chapter 177 of the Acts of 2022, an act aimed at addressing barriers to care for mental health. Moving forward, prior authorization from any provider (both in and out-of-network) is not required to determine medical necessity for these mental health services.

However, this doesn’t change the level of out-of-network benefits or associated cost-sharing detailed in the member’s plan benefits. This mandate also applies to out-of-state, inpatient psychiatric treatment.

Although this state mandate does not apply to self-insured accounts (ASCs), Blue Cross applies the same utilization review and prior authorization requirements to all members. This change aligns with our ongoing commitment to improve access to mental health care.

If you have any questions, contact your account executive.

Effective April 1, 2023, Upcoming Changes to the Standard Control with Advanced Control Specialty Formulary

Effective April 1, 2023, CVS Caremark^®', 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 select self-insured plans (500+) with the Standard Control with Advanced Control Specialty Formulary. 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
• Be added to the list of covered medications
• Be designated as preferred

Complete details about these changes will be available by February 24, 2023 in the What’s New section.

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.

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.