Plan Updates
Change in Authorization Requirements for Certain Musculoskeletal Services in 2023
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 these treatments on or after April 1, 2023.
If you have questions, call Team Blue at the Member Service number on your ID card.
* For the full list of services, members should check their plan details or call Member Service at the number on their ID card.
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 your plan benefits.
If you have any questions, call Team Blue at the Member Service number on your ID card.
Change in Prior Authorization Requirements for Certain Musculoskeletal Services in 2023
We're updating our prior authorization requirements for certain musculoskeletal (MSK) services for all HMO and PPO plan members* to go into effect in the spring of 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 these treatments on or after the effective date.
We’ll share more information on this upcoming change in early 2023. If you have questions, call Team Blue at the Member Service number on your ID card.
* For the full list of services, members should check their plan details or call Member Service at the number on their ID card.
NEW: Improving Health Outcomes Through Our Healthy Lives Program
Eligible members with complex medical and mental health conditions can now get an additional layer of support, at no additional cost, through our new Healthy Lives program. The services offered through the program are designed to help you better manage everyday health needs and are in addition to the care you already receive from your doctor.
Once enrolled in the program, you’ll work closely with a dedicated team of experts from the Brookline Center for Community Mental Health, an independent provider group that administers the program. Your team of community health workers, nurses, and licensed independent clinical social workers will provide personalized, one-on-one support, including:
- Assistance finding and maintaining the right medical and mental health care
- Educational materials
- Help with reaching your long-term health goals
If you’re eligible for the program, a Healthy Lives team member will contact you to set up an in-home assessment. Participation in this program is optional and won't affect your health plan benefits or coverage.
STOPPING THE FLU STARTS WITH YOU
Get your no-cost1 flu shot! If you haven’t gotten your flu shot yet, now’s the time. It will help protect you and everyone around you from getting sick, especially young children and older adults who are most at risk. The Centers for Disease Control and Prevention (CDC) says that it’s safe,2 effective, and can be given at the same time as the COVID-19 shot or booster. Get your no-cost1 flu shot at a convenient location near you. We’re in this together!
The Flu Shot Is Safe2 and Effective, with No Cost1 for Members
The flu vaccine is available at no additional cost from in-network providers like pharmacies, limited service clinics, and community health centers. You can also get the vaccine at no additional cost from your doctor if you have an upcoming appointment. To find a location near you, visit vaccines.gov.
Learn More
To learn more about the flu shot and how to avoid getting the flu, visit our flu page.
1. Flu vaccines recommended by the Centers for Disease Control and Prevention are covered in full when administered by an in-network provider. Exceptions may apply. Check plan materials for details.
2. The Centers for Disease Control and Prevention, “Influenza (Flu) Vaccine Safety,” August 25, 2022; cdc.gov/flu/prevent/vaccinesafety.htm
IT’S STILL FLU SEASON. TIME TO GET YOUR SHOT.
It’s never been more important to get your flu shot. Flu season can last all the way through May, and getting vaccinated will help protect you and everyone around you from getting sick during this crucial time. You can get vaccinated at no additional cost1 at in-network providers, limited service clinics, community health centers, and your doctor’s office. Get vaccinated today!
Learn More, including where to find your shot.
1. CDC-recommended flu vaccines are covered in full when administered by an in-network provider. Exceptions may apply. Check your plan materials for details.
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 your infused or injectable medications are 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 you a choice of where you receive your 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 You
If you:
- Receive one of the medications listed below, we continue to require prior authorization when the medication is covered under your medical benefits.
- Would like to have your medication infused or injected at an alternate site, such as through an in-home service, you can work with your doctor to transfer your 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 home infusion therapy providers to make this a smooth transition for you.
| Medications That Currently Require Prior Authorization | |
|---|---|
| Aralast | Lemtrada |
| Berinert | Onpattro |
| Cerezyme | Prolastin |
| Cinqair | Ruconest |
| Cinryze | Soliris |
| Elelyso | Tysabri |
| Entyvio | Ultomiris |
| Exondys 51 | Uplizna |
| Givlaari | Viltepso |
| Glassia | VPRIV |
| Haegarda | Vyepti |
| Ilumya | Vyondys 53 |
| Kalbitor | Xolair |
| Kanuma | Zemaira |
What This Means for Your Coverage
The Voluntary Site of Care Program applies to all medical plans except for the following plan types:
- - Federal Employee Program
- - Indemnity
- - Managed Blue for Seniors
- - Medex®´
- - Medicare Advantage
If you have any questions, call Team Blue at the Member Service number on your ID card.
Improving Care and Quality of Life for Select Members with Chronic Kidney Disease
Starting in early 2022, we’ll be offering select members in Massachusetts with chronic kidney disease personalized support, at no additional cost, to help manage their condition and improve their overall health.
If a member has chronic kidney disease, they may be eligible to participate in a program administered by Cricket Health, an independent company that provides personalized kidney care services. Enrolled members will learn more about their condition and how to manage its progression, and they'll get support for their day-to-day needs between medical appointments. Each enrolled member will have a dedicated Cricket Health care team consisting of a nurse, pharmacist, social worker, dietitian, and trained peer mentor they can chat with by phone or online through Cricket Health's digital platform, all at no additional cost.
If a member is eligible for this program, they will be contacted with more details and information on how to get started.
If you have any questions, please call Member Service at the number on the front of your ID card.
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 schoolwork, bodily tics, and other ailments.
This treatment coverage applies to all members except Medicare Advantage and Federal Employee Program members.
If you have questions, please call Team Blue at the Member Service number on your ID card.
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. 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. Providers will need to obtain prior authorization so that certain outpatient services will be covered for EPO and PPO plan members. This change help ensure you'll receive 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 any questions, please call Team Blue at the Member Service number on your ID card.
*Members should check their plan details for the full list of services, or call Member Service at the number on their ID card.
LET’S BEAT FLU. AGAIN!
Get your no-cost1 flu shot! If you haven’t gotten your flu shot yet, now’s the time. It will help protect you and everyone around you from getting sick, especially young children and the elderly who are the most at risk. All the work that we put in during the last flu season—record flu shots, hand-washing, social-distancing, and mask-wearing—really paid off, leading to the fewest flu cases ever. Let’s keep this going!
The Flu Shot Is Safe2 and Effective, and No Cost to You
The flu vaccine is available at no additional cost from in-network providers like pharmacies, limited service clinics, and community health centers. You can also get the vaccine at no additional cost from your doctor if you have an upcoming appointment. To find a location near you, visit vaccines.gov.
Learn More
To learn more about the flu shot and how to avoid getting the flu, visit our flu page.
1. Flu vaccines recommended by the Centers for Disease Control and Prevention (CDC) are covered in full when administered by an in-network provider. Exceptions may apply. Check plan materials for details.
2. Centers for Disease Control and Prevention, “Influenza (Flu) Vaccine Safety,” August 26, 2021.
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 your infused or injectable medications are 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 you a choice of where you receive your 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 You
If you:
- Receive one of the medications listed below, we continue to require prior authorization when the medication is covered under your medical benefits.
- Would like to have your medication infused or injected at an alternate site, such as through an in-home service, you can work with your doctor to transfer your 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 home infusion therapy providers to make this a smooth transition for you.
| Medications That Currently Require Prior Authorization | |
|---|---|
| Aralast | Lemtrada |
| Berinert | Onpattro |
| Cerezyme | Prolastin |
| Cinqair | Ruconest |
| Cinryze | Soliris |
| Elelyso | Tysabri |
| Entyvio | Ultomiris |
| Exondys 51 | Uplizna |
| Givlaari | Viltepso |
| Glassia | VPRIV |
| Haegarda | Vyepti |
| Ilumya | Vyondys 53 |
| Kalbitor | Xolair |
| Kanuma | Zemaira |
What This Means for Your Coverage
The Voluntary Site of Care Program applies to all medical plans except for the following plan types:
- - Federal Employee Program
- - Indemnity
- - Managed Blue for Seniors
- - Medex®´
- - Medicare Advantage
If you have any questions, call Team Blue at the Member Service number on your ID card.
Effective January 1, 2022, Coverage Changes for Infused or Injectable Medications Under the Medical Benefit
Blue Cross Blue Shield of Massachusetts is committed to covering infused or injected medications under the medical benefit for our members in the most cost-effective, clinically appropriate setting. We previously communicated that we would implement coverage changes for infused or injectable medications under the medical benefit on September 1, 2021. Blue Cross has decided to delay the implementation of this coverage change until January 1, 2022. We will provide updates to our members prior to the new implementation date, as appropriate. There is no further action needed for members who have already received prior authorization for their infused or injectable medication, or transitioned their care. Members and providers may also choose to initiate a request before the new effective date.
Upcoming Coverage Changes for Infused or Injectable Medications Under the Medical Benefit - DELAYED TO JANUARY 1, 2022
Effective September 1, 2021, we’re changing the covered sites of service where you can get infused or injectable medications administered. We’re also requiring prior authorization for these sites, as well as the medications listed below. These changes ensure that members are receiving care in clinically-appropriate, cost-effective settings.
Where to Get Infused or Injectable Medications
Starting September 1, 2021, infused or injectable medications will be covered at the following sites of service and require prior authorization:
- Doctor’s office
- Ambulatory infusion site
- Home infusion therapy provider. For more details, please see the Site of Care - Home Infusion Therapy Member Fact Sheet.
Infused or Injectable Medications That Require Prior Authorization
The following medications will require prior authorization when they’re administered in one of the sites of service listed above. These medications will require prior authorization in order to be covered. If prior authorization is already in place, your doctor won’t need to submit a new request until the current authorization expires.
| Medications That Currently Require Prior Authorization* | Additional Medications That Will Require Prior Authorization Starting September 1, 2021 | |
|---|---|---|
| Aralast | Lemtrada | Aldurazyme |
| Berinert | Onpattro | Benlysta |
| Cerezyme | Prolastin | Crysvita |
| Cinqair | Ruconest | Duopa |
| Cinryze | Soliris | Elaprase |
| Elelyso | Tysabri | Fabrazyme |
| Entyvio | Ultomoris | Krystexxa |
| Exondys 51 | Uplinza | Lumizyme |
| Givlaari | Viltepso | Naglazyme |
| Glassia | VPRIV | Ocrevus |
| Haegarda | Vyepti | Radicava |
| Ilumya | Vyondys 53 | Vimizim |
| Kalbitor | Xolair | |
| Kanuma | Zemaira | |
*Additional clinical criteria must be met to receive coverage for these medications.
What This Means for Your Coverage
As a result of these changes, members receiving infused or injectable medications may need to change where they get them to maintain coverage after September 1. If your prescribing doctor determines that treatment must be done in an outpatient hospital setting, they can contact us to request an exception.
| Members Without Prior Authorization | Members With Prior Authorization |
|---|---|
|
|
| We’ll contact impacted members in advance to help transition them to a covered site of service. | We’ll reach out to these impacted members to let them know about this change. |
This change will apply to all medical plans except for the following plan types:
- Federal Employee Program
- Indemnity
- Managed Blue for Seniors
- Medex®´
- Medicare Advantage
If you have any questions, please call Team Blue at the Member Service number on your ID card.
Changes to your telehealth benefit.
Starting on July 1, 2021, we will reinstate standard member costs for non-COVID medical- and mental-telehealth visits. How much you will pay depends on your health plan’s benefits. Medicare members are excluded from this change. The Federal Employee Program (FEP) follows guidelines from the Blue Cross Blue Shield Association regarding coverage for Federal Employee Program members. For more details, please see fepblue.org.
Since March 2020, we voluntarily and temporarily waived member costs for non-COVID telehealth visits to help ensure member access to health care services and to help prevent COVID-19 infection and illness. With the successful roll out of vaccines and the re-opening of states and businesses, this accommodation will end on July 1, 2021.
We will continue to waive costs for covered COVID-19 telehealth services as well as for COVID-19 in-person services when applicable. This includes COVID-19 vaccines.
New Prior Authorization Requirements for Select Medications Under the Medical Benefit
Starting July 1, 2021, the medications below are being added to our utilization management program, and will require your doctor to get prior authorization from us before the medications will be covered by your health plan. Prior authorization for these medications is required when administered in the following outpatient settings:
- Doctor’s office
- Home health care provider
- Home infusion therapy provider (if prior authorization is in place, no additional authorization is required until the member’s existing authorization expires)
- Outpatient hospital and dialysis settings
| Medications That Require Prior Authorization | ||||
|---|---|---|---|---|
| Mvasi | Riabni | Ruxience | Truxima | Zirabev |
When these medications are prescribed for oncology treatment, they must be submitted through the Quality Care Cancer Program, which launches July 1, 2021. When prescribed for non-oncology use, these medications will be subject to the current prior authorization process.
This change doesn’t affect these medications in inpatient, surgical day care, urgent care centers, and emergency department settings. It also doesn’t apply to Indemnity, Managed Blue for Seniors, group Medicare Advantage, group Medex®´, and Federal Employee Program members.*
*Check your plan details for your plan’s utilization management requirements, if applicable.
For more information, call Team Blue at the Member Service number on your ID card.
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.
| Oncology Medications That Will Be Covered Under Our Medical Benefit | ||
|---|---|---|
| Abraxane | Herceptin | Onivyde |
| Arzerra | Herceptin Hylecta | Ontruzant |
| Bavencio | Herzuma | Opdivo |
| Cyramza | Imfinzi | Poteligeo |
| Doxil/Lipodox | Kanjinti | Proleukin |
| Empliciti | Keytruda | Rituxan-Hycela |
| Fusilev | Khapzory | Tecentriq |
| Gazyva | Ogivri | Trazimera |
The Quality Care Cancer Program, which 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 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.
| Medications Moving from Our Medical to Pharmacy Benefit | |||
|---|---|---|---|
| Available at Retail Pharmacies | Durolane* | Gel-One* | GelSyn-3* |
| Monovisc* | Triluron* | Trivisc* | |
| Must Be Filled at a Specialty Pharmacy | Bynfezia | Cosentyx* | Dupixent* |
| Fasenra* | Kevzara* | Nucala* | |
| Siliq* | Strensiq | Tegsedi* | |
| Tremfya* | |||
Members who have plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex®’ plans** with a three-tier pharmacy benefit, or the National Preferred Formulary*** will receive coverage for these medications under their pharmacy benefit upon the effective date. Members with these plans will not experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit. 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.
Quality Care Cancer Program Launching July 1, 2021
We’re launching our new Quality Care Cancer Program on July 1, 2021, to help ensure that our members receive cancer care that is appropriate and safe, based on clinical guidelines. Through the Quality Care Cancer Program, board-certified oncologists and oncology-trained nurses will be available to discuss covered treatment options with our members’ doctors.
Our Quality Care Cancer Program applies to all commercial and Medicare Advantage plan members seeking outpatient medical oncology treatment (chemotherapy, immunotherapy, and supportive medications), or outpatient radiation oncology treatment. Doctors who order these types of treatments for our members will request Prior Authorization through AIM Specialty Health®´ (AIM), an independent company that will administer this program.
When a member’s doctor submits a treatment plan for prior authorization that meets evidence-based clinical criteria for the cancer being treated, they will get real-time approval. If the requested treatment doesn’t meet evidence-based criteria, the member’s doctor can request a peer-to-peer consultation with an AIM oncologist to discuss the covered, evidence-based treatments that are best for the member.
For a member already receiving cancer treatment at the time of the Quality Care Cancer Program’s launch, their doctor will need to request a prior authorization for the continuation of coverage. If a member’s treatment plan changes, their doctor will then request a new prior authorization for health plan coverage.
Because scientific and medical advances are rapidly changing cancer treatment, and there are wide variations in the way doctors treat patients with the same type of cancer, cancer care quality programs like ours are becoming necessary.
The Quality Care Cancer Program is designed to help our members receive the most appropriate and effective treatment regimen, so they can have the best possible outcome with the least number of side effects. If you have any questions, please contact member service.
Make a Plan to Get Your Flu Shot
Flu season can last through the end of May. And with COVID-19 it’s more important than ever to get your flu shot. It will keep you, your family, and community from getting sick during this crucial time. You can get your flu shot at no additional cost* from in-network providers like pharmacies, limited service clinics, and your doctor if you have an upcoming appointment.
Follow these steps, so you can plan out the easiest and safest way to get vaccinated:
- Find a location near you using vaccinefinder.org.
- Verify the location is in your network by signing in to MyBlue and visiting Find a Doctor & Estimate Costs.
- Make an appointment ahead of time, if possible. If not, ask when there are slower times during the week.
*CDC-recommended flu vaccines are covered in full when administered by an in-network provider. Exceptions may apply. Check your plan materials for details.
Added Behavioral Health Coverage for Children and Adolescents
Beginning January 1, 2021, upon plan renewal, Blue Cross Blue Shield of Massachusetts will cover the following behavioral health services for members under 19 years old:
- Family Support and Training (FS&T): medically necessary education for a child’s parent or caregiver, given in the home, to help resolve the child’s emotional or behavioral health needs and identify additional services and support in their community.
- Therapeutic Mentoring (TM): medically necessary services for a child, given in the home, to support the child’s social functioning, especially after an emotional or behavioral health disorder diagnosis. TM services may include supporting, coaching, and training the child in age-appropriate behaviors, interpersonal communication, problem-solving, conflict resolution, and relating appropriately to other children, adolescents, and adults.
These new services are in addition to the Intensive Community-Based Treatment (ICBT) behavioral health services we already cover for children and adolescents:
- In-Home Behavioral Services: Behavior Management Monitoring and Behavior Management Therapy
- In-Home Therapy: Therapeutic Clinical Intervention and Ongoing Therapeutic Training and Support
- Intensive Care Coordination
- Community-Based Acute Treatment for Children and Adolescents (CBAT)
- Intensive Community-Based Acute Treatment for Children and Adolescents (ICBAT)
- Mobile Crisis Intervention (MCI)
ICBT offers a family- and home-based treatment approach for children and adolescents; CBAT and ICBAT are forms of acute residential treatment. Wrap-around services are community-based interventions developed by a multidisciplinary team and personalized to focus on the strengths and needs of the child or adolescent and their family. ICBT services given outside Massachusetts may vary based on the state. Your Evidence of Coverage and other benefit documents will be updated when your plan is renewed.
If you have questions, call the Member Service number on your ID card.
Upcoming Prior Authorization Changes for Medications Covered Under the PPO and EPO Medical Benefit
Beginning January 1, 2021, we’re adding Prior Authorization requirements for members with PPO and EPO plans for certain medications covered under the medical benefit. In order for you to receive coverage for the medications included in the list, your doctor must first obtain Prior Authorization from us. If you’re currently using one of the listed medications, you’ll need an approved authorization to receive continued coverage.
To see the full list of medications that will require Prior Authorization, go to the Medication Lookup Tool and select Medical Benefit Prior Authorization Medication List under Important Information.
When coverage is requested for a medication that requires Prior Authorization, we review the request to determine whether the medication is medically necessary. We base the review on the patient’s diagnosis and medication history, as well as U.S. Food and Drug Administration and other evidence-based guidelines.
Prior Authorization is required for these medications when administered:
- In a clinician’s or physician’s office
- By a home health care provider
- By a home infusion therapy provider
- In an outpatient hospital or dialysis setting
This change doesn’t affect medications received in inpatient, surgical day care, urgent care, and emergency department settings. It also doesn’t apply to members of the following:
- Federal Employee Program
- Medex®´
- Managed Blue for Seniors
- Medicare*
- Indemnity
*Some Medicare plans have Prior Authorization requirements for medications. Please see your plan benefits for more details.
Benefits of Prior Authorization
- Ensures that covered medications are safe, effective, and medically necessary
- Avoids surprise out-of-pocket costs by confirming coverage before getting treatment
Questions?
If you have any questions, please call Member Service at the number on the front of your ID card.
This Year’s Flu Shot Is Crucial
COVID-19 means getting your flu shot is more important this year than ever. It will help keep you, your family, and community from getting sick. And it could keep you out of the doctor’s office at a time when so many others may need critical care. Plus, getting a flu shot is no-cost* and safe.
Where You Can Get a Flu Shot:
- Your In-network Primary Care Provider
- Limited Service Clinics (such as a MinuteClinic®´ at CVS)
- Urgent Care Centers
- Community Health Centers
- Public Access Clinics (available in some cities and towns, and may be available at no charge)
- Hospital Outpatient Departments
- Skilled Nursing Facilities, for members in outpatient care, like physical or occupational therapy
- Home Health Care Providers (in your home, or at a flu clinic hosted by a home health care provider)
- Certified Nurse/Midwife's Office
- Physician Assistant’s Office or Specialist Physician’s Office
- Nurse Practitioner’s Office
- Pharmacies
Visit our flu page to learn more about the flu shot, how to avoid getting the flu, and where to get the flu shot at no additional cost. You can also visit vaccinefinder.org to find out where the flu shot is available in your area.
*CDC-recommended flu vaccines are covered in full when administered by an in-network provider. Exceptions may apply. Check your plan materials for details.
We’re expanding our behavioral health coverage for children and adolescents
Beginning July 1, 2019, Blue Cross Blue Shield of Massachusetts insurance coverage will include the following services for members under 19 years old when medically necessary:
- In-Home Behavioral Health: Behavior Management Monitoring and Behavior Management Therapy
- In-Home Therapy : Therapeutic Clinical Intervention and Ongoing Therapeutic Training and Support
- Intensive Care Coordination
- Community Based Acute Treatment for Children and Adolescents (CBAT)
- Intensive Community Based Treatment for Children and Adolescents (ICBAT)
- Mobile Crisis Intervention
We already provide coverage for Community Based Acute Treatment for Children and Adolescents (CBAT), Intensive Community Based Treatment for Children and Adolescents (ICBAT), and Mobile Crisis Intervention. We refer to CBAT and ICBAT as Acute Residential Treatment or Subacute Care.
Effective July 1, 2020, coverage will include medically necessary Family Support and Training as well as Therapeutic Mentoring.
For questions about your health coverage, claims, and benefits, call the Member Service number on the front of your ID card.
Expanded coverage for fluoride supplements
Bright Futures, led by the American Academy of Pediatrics, has revised its recommendations for fluoride supplements to prevent dental cavities in children. As a result, effective January 1, 2019, as a one-day change, we’re updating our commercial medical plan coverage to reflect these changes, ensuring compliance with Preventive Services under the Affordable Care Act (ACA).
Our new coverage expands the age range to six months through 16 years of age. This benefit will be available at a $0 cost share for fully insured and self-insured non-grandfathered plans, as well as grandfathered accounts that adopted the ACA’s Preventive Services benefits. Coverage is subject to other health plan network requirements and provisions.
Help for members affected by California wildfires
As deadly wildfires continue to burn in California, Blue Cross Blue Shield is committed to providing support to all of our members who live in affected areas. To expedite access to care, we’re adjusting the following policies for members in impacted areas, including:
- Allowing early refills of prescription medications
- Waiving referral, authorization, and pre-certification requirements for medical and pharmacy services in areas that have been declared federal disaster zones
- Offering medical and behavioral health visits through Well Connection at no cost, with no copayments and no deductibles
Questions or concerns?
You can call Member Service at the number on your ID card or 1-800-262-2583. You can also call our 24/7 Nurse Care Line at 1-888-247-2583 to talk to a registered nurse.
Help for members affected by Hurricane Michael
Blue Cross Blue Shield of Massachusetts is saddened by the impact of Hurricane Michael. We’re committed to providing support to all members who live in affected areas of Florida. To help expedite access to care, we’re adjusting the following policies for members in impacted areas, including:
- Allowing early refills of prescription medications
- Waiving referral, authorization, and pre-certification requirements for medical and pharmacy services in areas that have been declared federal disaster zones
Questions or concerns?
You can call Member Service at the number on your ID card or 1-800-262-2583. You can also call our 24/7 Nurse Care Line at 1-888-247-2583 to talk to a registered nurse.
Prior authorization request required for genetic testing
Beginning January 1, 2019, your doctor will need to request prior authorization from us before we cover the cost of certain genetic tests. What are genetic tests? These tests can help identify medical risks that run in your family or find any DNA changes related to a specific disease. If a doctor requests these procedures for you, he or she may also suggest genetic counseling to help you better understand the test results.
The following genetic tests will require prior authorization:
- DNA testing of hereditary heart disease risks
- DNA testing of hereditary cancer risks
- Testing to detect changes in DNA which may indicate a specific disease or condition
- Testing to help select proper medication and dosing regimens
- Prenatal screening and diagnosis of specific conditions
- DNA testing of tumor cells
- DNA sequencing to understand a current health or medical issue
To learn more about these procedures, read our fact sheet or visit ahealthyme.com.
What is prior authorization?
The prior authorization process ensures you receive health care services that are medically necessary for you and covered by your health plan.
Questions?
If you have any questions, call the Member Service number on the front of your ID card.
Contraceptives mandate in Massachusetts
On Monday November 20, 2017, Governor Baker signed into law the Advancing Contraceptive Coverage and Economic Security in our State (ACCESS) bill. This law requires coverage with no cost share for the following contraceptive methods and services for women:
- Food and Drug Administration (FDA)-approved contraceptive drugs, devices and other products (excludes male condoms)
- FDA-approved over-the counter emergency contraception
- Voluntary female sterilization procedures
- Patient education and counseling on contraception
- Follow-up services related to the drugs, devices, products, and procedures
Dispensing requirement
By Massachusetts state law, contraceptives can be dispensed for an initial fill for a 3-month period and then, a 12-month period. A prescription may be dispensed all at once, or over the course of the 12-month period, regardless of coverage.
Who does this impact?
As a Blue Cross Blue Shield of Massachusetts member, contraceptives are already covered, so you'll experience no disruption to your plan or coverage.
Questions?
Contact Member Service using the number on your ID card for help with any questions related to your health plan.
You're getting access to more dentists
Beginning January 1, 2018, Dental Blue® members will be able to get service from nearly 122,000 dentists, and 300,000 provider locations across the country through our Dental Blue National Network. This new network is one of the largest in the country, and is nearly twice the size of our current national network. To reflect this change, you'll receive a new member ID card in November. In addition, we've updated our online Find a Doctor & Estimate Costs tool to include zip code and plan type searches, making it easier for you to find nearby dentists and locations. You also won't have to conduct separate searches for dentists outside Massachusetts.
Support for our members impacted by recent hurricanes
Blue Cross Blue Shield of Massachusetts is saddened by the impact of Hurricane Irma. We're committed to providing support to all our members who live in affected areas of Florida and Puerto Rico. To help expedite access to care, we're adjusting the following policies for members in impacted areas:*
- Allowing early refills of prescription medications
- Waiving referral, authorization, and pre-certification requirements for medical, pharmacy and dental services
- Processing claims for services rendered by out-of-network providers at the member's in-network level of benefits
If members have questions or concerns
Members can call Member Service at the number on their ID cards or 1-800-262-2583. They can also call our 24/7 Nurse Care Line at 1-888-247-2583 to talk to a registered nurse.
If you have questions, please contact your account executive.
*The adjusted policies will be in place for four weeks and reevaluated as necessary.
Enhancements to imaging and sleep management programs
We're improving how we manage our imaging and sleep services, increasing the quality and efficiency of both services for members and employers. We now require prior authorization for all imaging and sleep services included in our management programs. AIM Specialty Health (AIM) will manage authorizations. AIM has experience managing imaging and sleep services for our HMO members, as well as for most other Blue plans with approximately 42 million lives under management across the country.
For our HMO members
The imaging management program, which has been in place since 2005, will move to a full Utilization Management (UM) program for procedures that require a pre-service prior authorization. A UM program requires a Medical Necessity determination prior to the coverage of services. We'll continue to exclude certain provider groups in Massachusetts from the management process when those groups meet established criteria.
Your sleep management program, which has been in place since 2013, already requires authorization before the service, and so is unchanged.
All provider groups in Massachusetts participate in this process.
For our PPO members
New requirements for pre-service authorization will go into effect for in-state and out-of-state services. As a result of this change, if out-of-state PPO members don't obtain pre-service authorization, they'll be financially responsible for the cost of services. As with our HMO programs, some Massachusetts provider groups may be excluded from the management requirements for imaging, and all provider groups are required to participate in the sleep management program.
Learn more
To learn more about these enhancements and how they impact you, please review our fact sheet here.
Questions?
If you have any questions, please contact Member Service using the number on the front of your Member ID card.
Coverage for 3D mammograms begins in 2017
Regular screenings are the best way to find breast cancer at an early stage, when treating the disease has the highest success rates. Blue Cross Blue Shield of Massachusetts suggests that members talk to their doctor about the benefits and timing of mammogram screenings for their age and health history. In addition to coverage for standard mammography screenings, on January 1, 2017, we began providing coverage for 3D mammograms (digital breast tomosynthesis), subject to the same guidelines as standard mammograms.
Provider tier update for Blue Options v. 5 and Hospital Choice Cost Sharing
As a result of favorable improvements in the following hospitals' cost or quality performance, we updated their tier in our Blue Options v.5 benefit designs and Hospital Choice Cost Sharing benefit designs. This one-day change is effective for all plans and accounts on January 1, 2017. With this update, members will have lower out-of-pocket costs when receiving services at these hospitals.
Blue Options v.5
| Hospital | Previous Blue Options Tier | New Blue Options Tier | Reason for Tier Improvement |
|---|---|---|---|
| Sturdy Memorial Hospital | Basic Benefits Tier | Standard Benefits Tier | Met moderate cost benchmark |
| Nashoba Valley Medical Center | Standard Benefits Tier | Enhanced Benefits Tier | Met quality benchmark |
Hospital Choice Cost Sharing
| Hospital | Previous HCCS Cost Share | New HCCS Cost Share | Reason for Tier Improvement |
|---|---|---|---|
| Sturdy Memorial Hospital | Higher Cost Share | Lower Cost Share | Met moderate cost benchmark |
If you have any questions, please contact your account executive.
Safely dispose of expired or unwanted drugs on October 22, 2016
Medications don't last forever. Over time, their chemical properties change, making them less effective and even dangerous. The U.S. Drug Enforcement Administration's next National Prescription Drug Take Back Day is on Saturday, October 22, 2016, from 10:00 a.m. to 2:00 p.m.
Now is a great time to go through your medicine cabinet and check the expiration dates on your medications on everything from aspirin to prescription drugs. Take all those expired medications and bring them to your local disposal location. To find Take Back locations in your area, please use the U.S. Drug Enforcement Administration's search tool.
Blue Options and Hospital Choice Cost Sharing update on provider tiers
As of January 1, 2016, we updated the hospital and primary care provider tiers for our Blue Options and Hospital Choice Cost Sharing (HCCS) plans.
Why we updated our tiers
In order to maintain the affordability of our tiered network plans, we periodically review and update our tiers based on the most current provider data. This process encourages the hospitals and doctors in our networks to continue to improve their cost and quality performance.
We analyze our tiers based on standard performance measurement principles accepted by local and national physician leaders and measurement experts. This is our fifth update to our tiered network plans.
How the update affects you
The tier update will change the costs for care received from some doctors and hospitals. Your costs may go up or down, depending on whether a tier is changed for any of your doctors or hospitals.
If you're a Blue Options member, the tier changes will go into effect when your plan is renewed. If your plan includes Hospital Choice Cost Sharing, the tier changes was effective for all members on January 1, 2016. The tier update will be identified on member ID cards and in our provider directory as Blue Options v.5.
To find the benefits tier of a provider, use our search tool at Find a Doctor & Estimate Costs. The new provider tiers will be available October 1, 2015.
As of January 1, 2016, members of our HMO Blue New England Options plans have access to tiered providers in New Hampshire. This change was effective on your plan renewal. The plans include:
- HMO Blue New England Options
- HMO Blue New England Options Deductible
- HMO Blue New England Options Deductible II
- HMO Blue New England Options Deductible III
Members in these plans already have access to participating providers from six networks within the New England states. These members will continue to have access to the same network of providers as they do today in New England.
However, New Hampshire doctors and hospitals have been placed into one of two benefit tiers. Member costs for care from some doctors and hospitals in New Hampshire have changed, depending on the new tier a doctor or hospital is in.
A network primary care provider or network hospital in NH will now be either:
- A Tier 1 (Enhanced Benefit Tier) provider
- A Tier 2 (Standard Benefits Tier) provider
Network doctors and general hospitals in the New England network located outside of Massachusetts or New Hampshire will continue to be in the Enhanced Benefits Tier.
For New England plans with the Hospital Choice Cost Sharing feature, there is no change to the member's cost share. All New Hampshire hospitals are considered "Lower Cost Share".
To find the benefits tier of a provider, use our search tool at Find a Doctor & Estimate Costs. Search for HMO Blue New England Options v.5.
Important changes to your medical benefits in 2016
On January 1, 2016, some of your benefits will change to keep your plan current with the Affordable Care Act. There is nothing you need to do—we simply want you to be aware of the upcoming changes.
Out-of-pocket costs
- Maximum out-of-pocket limits will be $6,850 per individual and $13,100 per family.
- Maximum out-of-pocket rules for HSA-qualified Saver plans will ensure no one member pays more than the individual out-of-pocket maximum.
- Your copayments, co-insurance, or deductibles may change.
Pediatric dental benefits
Pediatric dental coverage will be extended through the end of the month a child turns 19.
Pharmacy coverage
- A new tier for lower-cost generic medications (Tier 1) is being introduced.
- Instead of a 3-tier pharmacy benefit, you will have a new 4-tier pharmacy benefit.
- Out-of-pocket cost will be waived for qualified smoking cessation drugs.
- Certain formulary exceptions will change.
Provider tiers update: Blue Options and Hospital Choice Cost Sharing plans
- The tier update will change your costs for care received from some doctors and hospitals.
- Your costs will go up or down depending on the new tier your doctor or hospital is in.
Provider tiers update: HMO Blue New England options
- Members will have access to tiered providers in New Hampshire.
- New Hampshire doctors and hospitals will be placed into one of two benefit tiers.
- Member costs in NH will change depending on the new tier a doctor or hospital is in.
- For plans with the Hospital Choice Cost Sharing feature, there is no change to member out-of-pocket costs.
New plan designs for individuals
You will have more plan choices! We are pleased to announce several new plan designs, effective January 1, 2016:
- Access Blue New England Saver $2,500
- Access Blue New England Saver $3,000
- HMO Blue New England $1,000 Deductible with Copayment with Hospital Choice Cost Sharing
- HMO Blue New England $1,500 Deductible with Hospital Choice Cost Sharing
- Preferred Blue PPO Options Deductible II
- Preferred Blue PPO Options Deductible III
Get ready for our newly improved Find a Doctor and Estimate Costs tool!
Providing you with simple and actionable information regarding provider health care cost and quality is an important ingredient in helping you take control of your health care. Later this year, we'll unveil our newly redesigned Find a Doctor and Estimate Costs tool, giving you a better user experience. Soon you will be able to:
- Conduct intuitive searches making it easier to find what you need, when you need it
- Compare up to 10 providers side-by-side
- Read and write reviews on doctors
- Access an expanded selection of cost estimation features