Plan Updates

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