Pharmacy Benefit Updates

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

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

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

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

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

Medications No Longer Covered Starting January 1, 2024

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

Medication Class	Medication Name	Covered Alternative
Antibiotics	Doxycycline Hyclate 75 mg and 150 mg	Doxycycline 50 mg and 100 mg
Bisphosphonates	Actonel	Risedronate
Continuous Glucose Monitors*	Enlite Eversense Guardian	Dexcom Freestyle Libre
Iron Reducers	Exjade Jadenu	Deferasirox
	Ferriprox	Deferiprone
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)*	Indocin suspension	Naproxen suspension
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)	Diclofenac 25 mg capsules	Diclofenac 50 mg
	Diclofenac 2% suspension	Diclofenac 1.5%
	Ketoprofen 200 mg ER	Ketoprofen
	Meloxicam Submicronized	Meloxicam
Oral Corticosteroids*	Prednisolone 5 mg	Prednisone
Steroid Inhalers	Flovent Diskus Flovent HFA	Fluticasone Propionate
Steroid Combination Inhalers	Symbicort	Breyna
Topical Antimicrobials	Noritate	Metronidazole
Topical Antifungal - Onychomycosis	Tavaborole	Ciclopirox
Tyrosine Metabolism Inhibitor	Orfadin	Nitisinone
Urinary Retention Agents	Uroxatral	Alfuzosin ER

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

Medications with New Quality Care Dosing (QCD) Limit

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

Medication Class	Medication Name	New Coverage Limit
COVID-19 treatment	Paxlovid	One (1) carton per fill (enough to treat per FDA), and one (1) fill for 5 days every 30 days

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:

Acetadote	Dichlorphenamide	Lynparza	Synarel
Arcalyst	Emflaza	Lytgobi	Tazicef
Asparlas	Estradiol Valerate	Marqibo	Testosterone Enanthate
Bicillin L-A	Evomela	Mektovi	Tiopronin
Braftovi	Fortaz	Mugard	Tlando
Calquence	Gavreto	Nitisinone	Uptravi
Carglumic Acid	Inbrija	Nityr	Ventavis
Cometriq	Ingrezza	Onpattro	Veozah
Cutaquig	Ingrezza Initiation Pack	Portrazza	Vincasar PFS
Cystaran	Jatenzo	Qutenza	Vyepti
Daraprim	Jayvygtor	Reblozyl	Vyxeos
Deferoxamine Mesylate	Jynarque	Rimso-50	Yondelis
Delestrogen	Kanuma	Rolvedon	Yonsa
Depo-Estradiol	Koselugo	Romidepsin	Zejula
Desferal Mesylate	Kyzatrex	Sajazir	Zydelig

Prior Authorization Now Required for Briumvi and Ocrevus

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

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

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

Coverage Changes for Certain Medications Being Removed from Our Medical Benefit

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

• Simponi Aria
• Stelara

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

Medical Policy Updates

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

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

For This Policy	Update
Immune Modulating Drugs Policy (004)	This policy will be updated to reflect the removal of medical benefit coverage for Simponi Aria and Stelara mentioned above.   Dosing and frequency of use will be required as part of prior authorization for the following medications: Actemra (non-preferred), Avsola (preferred), Orencia (non-preferred), Inflectra (preferred), Infliximab (non-preferred), Remicade (non-preferred), Renflexis (non-preferred). These medications are covered under the pharmacy benefit, and the medical benefit for providers that signed the medical benefit amendment to buy and bill.
Injectable Asthma Medications (017)	Dosing and frequency of use will be required as part of prior authorization for Xolair in order to be covered under the medical benefit.
Medication Utilization Management (MED UM) & Pharmacy Prior Authorization (033)	This medical policy will be updated to include Briumvi and Ocrevus. Prior authorization will be required for new and existing prescriptions to be covered under the medical or pharmacy benefit.   Tysabri currently requires prior authorization under the medical benefit and will require prior authorization under the pharmacy benefit, effective January 1, 2024.   Dosing and frequency of use will be required as part of prior authorization for the following medications in order for them to be covered under the medical benefit: Prolia, Tepezza, Xgeva.
Bisphosphonates, Oral (058)	This policy will be retired on January 1, 2024.
Injectable Specialty Medication Coverage (071)	This policy will be updated to include Simponi Aria and Stelara.
Vascular Endothelial Growth Factor (VEGF) Inhibitors Step Therapy (092) – Medical Benefit	This policy will be updated to remove Alymsys, MVASI, Vegzelma and Zirabev.   This policy is changing to a prior authorization policy and all Step 2 and Step 3 medications under this policy will transition from a step therapy to a prior authorization requirement. Prior authorization will be required for new prescription for any medication under this policy.
Soliris, Ultomiris, Myasthenia Gravis, and Neuromyelitis Optica Policy (093)	Dosing and frequency of use will be required as part of prior authorization for Soliris in order to be covered under the medical benefit.
Quality Care Cancer Program (Medical Oncology) (099)	Riabni will move from preferred to non-preferred and Truxima will move from non-preferred to preferred for new prescriptions. Prior authorization through Carelon Medical Benefit Management, as part of the Quality Care Cancer Program, will continue to be required.
Supportive Care Treatments for Patients with Cancer (105)	Fulphila will move from preferred to non-preferred for new prescriptions.
Nononcologic Uses of Rituximab (123)	Dosing and frequency of use will be required as part of prior authorization for the following medications in order for them to be covered under the medical benefit: Riabni, Rituxan, Ruxience, Truxima.
Entyvio (Vedolizumab) Policy (162)	Dosing and frequency of use will be required as part of prior authorization for Entyvio in order to be covered under the medical benefit.
Multiple Sclerosis, Prior Auth & Step Policy (839)	Prior authorization will be required for new prescriptions of Kesimpta.   The following medications will no longer require step therapy but will require prior authorization to be covered. This applies to new prescriptions for these medications: Avonex, Betaseron, Extavia, Plegridy, Rebif.

Looking for More Information?

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

Questions?

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

---

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

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

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

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

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

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

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

---

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

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

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

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

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

Medications No Longer Covered Starting July 1, 2023

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

Medication Class	Medication Name	Covered Alternative
Topical Anti-psoriatic	calcipotriene - betamethasone dipropionate topical suspension Taclonex suspension	clobetasol shampoo
Prenatal Vitamins	Atabex EC Atabex OB Azesco Bal-Care DHA C-Nate DHA CitraNatal CitraNatal 90 DHA CitraNatal Assure CitraNatal B-Calm CitraNatal Bloom CitraNatal DHA CitraNatal Harmony Complete Natal DHA pak CompleteNate chew Co-natal FA Concept DHA Concept OB Duet DHA 400 mis 25-1-400 Duet DHA Balanced EnBrace HR Folivane-OB cap Jenliva Koshr prenatal tab 30-1mg M-Natal Plus tab Multi-Mac tab Mynatal tab Mynatal tab advance Mynate 90 tab plus Natachew chew Natalvit tab 75-1mg NeevoDHA Neonatal Complete Neonatal Complete tab Neonatal DHA Neonatal FE tab Neonatal Plus Neonatal Plus tab 27-1mg Nestabs tab Nestabs DHA pak Nestabs one cap Niva-plus OB Complete/cap DHA OB Complete one OB Complete petite OB Complete tab OB Complete tab premier Obstetrix One cap 38-1-225 Obstetrix DHA pak Obstetrix EC tab O-Cal tab prenatal One Vite plus PNV-DHA cap docusate PNV-omega cap PNV tabs tab 29-1mg PR Natal 400 pak PR Natal EC 400 pak Pregen DHA cap Pregenna tab Premesis Rx tab Prena1 chew Prena1 Pearl cap Prena1 True Prenaissance cap Prenaissance Plus cap Prenara cap prenatal Prenatal 19 chew 29-1mg Prenatal+FE tab 29-1mg Prenatal tab 27-1mg Prenatal vitamin tab low iron Prenate Prenate AM tab 1mg Prenate chew 0.6-0.4 Prenate DHA Prenate Elite tab Prenate Enhance cap Prenate Essential Prenate Mini Prenate Restore cap Prenatal-u cap 106.5-1 Prenatal tab 27-1mg Prenatal tab plus Prenatvite Complete tab Prenatvite Plus tab Prenatvite Rx tab Preplus tab 27-1mg Pretab tab 29-1mg Primacare cap Provida OB cap R-natal OB cap 20-1-320 Redichew Rx chew Relnate DHA cap Se-Natal 19 tab Se-Natal 19 chew Select-OB chew Select-OB+DHA pak Taron-C DHA cap Taron-Prex cap Thrivite Rx tab 29-1mg TriCare prenatal Trinatal Rx tab 1 Tri-Tabs DHA mis TriStart DHA TriStart Free cap TriStart One cap 35-1-215 Triveen-duo pak DHA Vinate One tab Vinate II tab Vinate DHA cap 27-1.13 Vitatrue mis Virt-Nate cap DHA Virt-PN Plus cap Vitafol chew gummies Vitafol FE+cap Vitafol-Nano Vitafol-Nano tab Vitafol-OB Vitafol-OB pak +DHA Vitafol-One cap Vitafol Ultra vitaMedMD One Rx Vitapearl Vitathely Virt-C DHA cap Virt-PN DHA cap Viva DHA cap Vol-Plus Vol-Tab Rx tab VP-PNV-DHA cap Wescap-C DHA cap Wescap-PN DHA cap Wesnate DHA cap Westab Plus tab 27-1mg Westgel DHA cap Zalvit tab 13-1mg Zatean-PN DHA cap Zatean-PN Plus cap Ziphex	Elite OB tab Inatal GT tab Prenatabs Rx tab Prenatal 19 chew tab PNV-DHA cap PNV-Select tab Trinate tab

Medications with New Quality Care Dosing (QCD) Limit

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

Medication Class	Medication Name	New Coverage Limit
Tetracycline Antibiotic	Nuzyra 150 mg Tablet ONLY	30 tablets per 30 days

 

Medications Switching Tiers

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

Medication Class	Medication Name	2023 Tier for members with a three-tier pharmacy benefit	2023 Tier for members with a four-tier pharmacy benefit	2023 Tier for members with a five-tier pharmacy benefit	2023 Tier for members with a six-tier pharmacy benefit
Monoclonal Antibodies	Nucala2	Tier 2a	Tier 3b	Tier 4c	Tier 5d
	Xolair2	Tier 2a	Tier 3b	Tier 4c	Tier 5d

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

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

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

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

• Ilumya
• Skyrizi

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

Medical Policy Updates

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

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

For this policy	Update
Immune Modulating Drugs Policy (004)	This policy will be updated to reflect the medical to pharmacy benefit coverage change for Ilumya and Skyrizi as noted below in the Injectable Specialty Medication Coverage Policy (071).
Immunomodulators for Skin Conditions Policy (010)	Rinvoq coverage criteria will be updated to require the use of another systemic medication other than Dupixent, before it’s covered. The Drug-Systemic step table in this policy will be updated from a three-step to a two-step and will require the use of two Step 1 medications prior to a Step 2 medication being approved. As a result, Cibinqo will move from Step 3 to Step 2 with in this policy. This will apply to you if these medications are newly prescribed.
Injectable Asthma Medications Policy (017)	A prescription by a specialist will no longer be required in order for Xolair to be covered. Prior authorization will be required for new prescriptions.
Injectable Specialty Medication Coverage Policy (071)	Ilumya and Skyrizi will be added to this policy. These medications will be covered only under the pharmacy benefit starting July 1, 2023 and prior authorization will be required for new prescriptions.
Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033)	Step therapy requirements will be updated to require the use of a steroid and tacrolimus or pimecrolimus, before covering Dupixent (when used to treat atopic dermatitis, also known as eczema).

 

Looking for More Information?

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

Questions?

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

---

Quality Care Dosing Limits Have Increased for Select Medications

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

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

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

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

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

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

---

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

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

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

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

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

Questions?

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

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

---

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

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

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

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

Medications No Longer Covered Starting January 1, 2023

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

Medication Class	Medication Name	Covered Alternative
Antidiabetic — Dipeptidyl Peptidase-4 (DPP4) Enzyme Inhibitor and Combinations	Kombiglyze XR1 Onglyza1	Glyxambi1 Janumet1 Janumet XR1 Januvia1 Trijardy XR1
Antidiabetic — Glucagon-like Peptide-1 (GLP1) Receptor Antagonists (injectable)	Bydureon1 Bydureon BCise1 Byetta1	Ozempic1 Trulicity1 Victoza1
Inflammatory Conditions	Actemra1,2.3 Actemra ACTPen1,2,3 Cimzia1,2 Ilumya1,2 Kineret1,2 Olumiant1,2 Orencia1,2 Orencia ClickJect1,2 Siliq1,2 Simponi1,2	Enbrel1 Humira1 Kevzara1 Otezla1 Rinvoq ER1 Skyrizi1 Stelara1 Taltz1 Tremfya1 Xeljanz1 Xeljanz XR1
Migraine Treatment — Calcitonin Gene-Related Peptide (CGRP)	Qulipta1,2 Vyepti1,2,3	Aimovig1 Ajovy1 Emgality1 Nurtec1
Multiple Sclerosis Treatment	Bafiertam1,2,3	dimethyl fumarate

1. This medication also has prior authorization and/or step therapy requirements.
2. If you currently use this medication, you’ll continue to be covered until your prior authorization expires.
3. If you use this medication, you’ll experience a copay increase as of January 1, 2023.

Medications Excluded from Coverage

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

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

Medications Switching Tiers

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

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

Medication Class	Medication Name	2023 Tier for members with a three-tier pharmacy benefit	2023 Tier for members with a four-tier pharmacy benefit	2023 Tier for members with a five-tier pharmacy benefit	2023 Tier for members with a six-tier pharmacy benefit
		Antidiabetic – GLP1 Receptor Antagonists (injectable)	Ozempic* Victoza*	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Antidiabetic – GLP1 Receptor Antagonist (oral)	Rybelsus*	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Antiobesity (injectable)	Contrave XR* Saxenda*	Tier 2a	Tier 3b	Tier 2a	Tier 3b
Irritable Bowel Syndrome Treatment (oral)	Xifaxan*	Tier 3e	Tier 4e	Tier 3e	Tier 4e
Multiple Sclerosis Treatment	Aubagio*	Tier 2a	Tier 3b	Tier 4c	Tier 5d
	Vumerity*	Tier 2e	Tier 3e	Tier 4e	Tier 5e

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

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

Medical Policy Updates

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

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

For this policy	Update
Anti-Migraine Policy (021)	Qulipta and Vyepti are moving from covered to non-covered. Prior authorization requirements will still apply. If you currently use these medications, you’ll continue to be covered until your prior authorization expires. The prescription lookback period for step therapy is changing for the following medications: Aimovig, Ajovy, and Emgality. This applies to you if these medications have been newly prescribed.
Diabetes Step Therapy (041)	Bydureon, Bydureon BCise, Byetta, Kombiglyze XR, and Onglyza are moving from covered to non-covered. As a result, these medications will move from Step 2 to Step 3 within this policy. If you currently use these medications, or if they’re newly prescribed, new prior authorization is required. Ozempic, Rybelsus, and Victoza are moving from non-covered to covered. As a result, these medications will move from Step 3 to Step 2 within this policy.
Immune Modulating Medications (004)	All medications in this policy will move from indication-based prior authorization to non-indication-based prior authorization. Preferred medications must be used before non-preferred medications will be approved and covered. Actemra, Actemra ACTPen, Cimzia, Ilumya, Kineret, Olumiant, Orencia, Orencia ClickJect, Siliq, and Simponi are moving from covered to non-covered. If you currently use these medications, you’ll continue to be covered until your prior authorization expires. Some members currently using these medications will experience an increase in out-of-pocket costs. If these medications are newly prescribed for you, prior authorization is required.
Drug Management and Retail Pharmacy Prior Authorization Policy (049)	Xifaxan will move from non-covered to covered. Prior authorization requirements will be required to check against Food and Drug Administration requirements. If you currently use these medications, you’ll continue to be covered until your prior authorization expires.
Multiple Sclerosis Step Therapy (839)	Prior authorization will be required for the following medications, to check against Food and Drug Administration requirements: Aubagio, Gilenya, Mavenclad, Mayzent, Vumerity, and Zeposia.

Looking for More Information?

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

Questions?

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

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

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

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

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

Medications No Longer Covered Starting January 1, 2023

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

Medication Class	Medication Name	Covered Alternative
Antidiabetic — Dipeptidyl Peptidase-4 (DPP4) Enzyme Inhibitor and Combinations	Kombiglyze XR1 Onglyza1	Glyxambi1 Janumet1 Janumet XR1 Januvia1 Trijardy XR1
Antidiabetic — Glucagon-like Peptide-1 (GLP1) Receptor Antagonists (injectable)	Bydureon1 Bydureon BCise1 Byetta1	Ozempic1 Trulicity1 Victoza1
Inflammatory Conditions	Actemra1,2.3 Actemra ACTPen1,2,3 Cimzia1,2 Ilumya1,2 Kineret1,2 Olumiant1,2 Orencia1,2 Orencia ClickJect1,2 Siliq1,2 Simponi1,2	Enbrel1 Humira1 Kevzara1 Otezla1 Rinvoq ER1 Skyrizi1 Stelara1 Taltz1 Tremfya1 Xeljanz1 Xeljanz XR1
Migraine Treatment — Calcitonin Gene-Related Peptide (CGRP)	Qulipta1,2 Vyepti1,2,3	Aimovig1 Ajovy1 Emgality1 Nurtec1
Multiple Sclerosis Treatment	Bafiertam1,2,3	dimethyl fumarate

1. This medication also has prior authorization and/or step therapy requirements.
2. If you currently use this medication, you’ll continue to be covered until your prior authorization expires.
3. If you use this medication, you’ll experience a copay increase as of January 1, 2023.

Medications Excluded from Coverage

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

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

Medications Switching Tiers

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

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

Medication Class	Medication Name	2023 Tier for members with a three-tier pharmacy benefit	2023 Tier for members with a four-tier pharmacy benefit	2023 Tier for members with a five-tier pharmacy benefit	2023 Tier for members with a six-tier pharmacy benefit
		Antidiabetic – GLP1 Receptor Antagonists (injectable)	Ozempic* Victoza*	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Antidiabetic – GLP1 Receptor Antagonist (oral)	Rybelsus*	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Antiobesity (injectable)	Contrave XR* Saxenda*	Tier 2a	Tier 3b	Tier 2a	Tier 3b
Irritable Bowel Syndrome Treatment (oral)	Xifaxan*	Tier 3e	Tier 4e	Tier 3e	Tier 4e
Multiple Sclerosis Treatment	Aubagio*	Tier 2a	Tier 3b	Tier 4c	Tier 5d
	Vumerity*	Tier 2e	Tier 3e	Tier 4e	Tier 5e

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

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

Medical Policy Updates

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

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

For this policy	Update
Anti-Migraine Policy (021)	Qulipta and Vyepti are moving from covered to non-covered. Prior authorization requirements will still apply. If you currently use these medications, you’ll continue to be covered until your prior authorization expires. The prescription lookback period for step therapy is changing for the following medications: Aimovig, Ajovy, and Emgality. This applies to you if these medications have been newly prescribed.
Diabetes Step Therapy (041)	Bydureon, Bydureon BCise, Byetta, Kombiglyze XR, and Onglyza are moving from covered to non-covered. As a result, these medications will move from Step 2 to Step 3 within this policy. If you currently use these medications, or if they’re newly prescribed, new prior authorization is required. Ozempic, Rybelsus, and Victoza are moving from non-covered to covered. As a result, these medications will move from Step 3 to Step 2 within this policy.
Immune Modulating Medications (004)	All medications in this policy will move from indication-based prior authorization to non-indication-based prior authorization. Preferred medications must be used before non-preferred medications will be approved and covered. Actemra, Actemra ACTPen, Cimzia, Ilumya, Kineret, Olumiant, Orencia, Orencia ClickJect, Siliq, and Simponi are moving from covered to non-covered. If you currently use these medications, you’ll continue to be covered until your prior authorization expires. Some members currently using these medications will experience an increase in out-of-pocket costs. If these medications are newly prescribed for you, prior authorization is required.
Drug Management and Retail Pharmacy Prior Authorization Policy (049)	Xifaxan will move from non-covered to covered. Prior authorization requirements will be required to check against Food and Drug Administration requirements. If you currently use these medications, you’ll continue to be covered until your prior authorization expires.
Multiple Sclerosis Step Therapy (839)	Prior authorization will be required for the following medications, to check against Food and Drug Administration requirements: Aubagio, Gilenya, Mavenclad, Mayzent, Vumerity, and Zeposia.

Looking for More Information?

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

Questions?

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

---

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

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

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

Questions?

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

---

Metro Drugs Is Leaving Our Specialty Pharmacy Network for Fertility Medications

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

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

Questions?

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

---

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

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

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

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

Medications Switching Tiers

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

Medication Class	Medication Name	2022 Tier for members with a three-tier pharmacy benefit	2022 Tier for members with a four-tier pharmacy benefit	2022 Tier for members with a five-tier pharmacy benefit	2022 Tier for members with a six-tier pharmacy benefit
		Inflammatory Conditions	Avsola	Tier 2a	Tier 3b	Tier 4c	Tier 5d
Neulasta	Tier 2a		Tier 3b	Tier 4c	Tier 5d
Ziextenzo	Tier 2a		Tier 3b	Tier 4c	Tier 5d

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:

Policies	Update	Date of Change
Dificid (fidaxomicin) (700)	This step therapy policy has been discontinued. We no longer require members to have prior treatment or failure with vancomycin before covering Dificid (fidaxomicin). Members who have an approved exception to cover Dificid (fidaxomicin) don’t need their doctors to renew this request.	3/1/2022
Immune Modulating Drugs (004)	Avsola will move from non-preferred to preferred within the Remicade and infliximab biosimilars policy section. Inflectra and Avsola will now be the preferred medications in this policy.	4/1/2022
Quality Care Cancer Program (Medical Oncology) (099) Nononcologic Uses of Rituximab (123)	Riabni will move from non-preferred to preferred. Truxima will move from preferred to non-preferred. Ruxience and Riabni will now be the preferred medications in these policies. Members currently using Truxima will have continued coverage so their care isn’t disrupted.	7/1/2022
Quality Care Cancer Program (Medical Oncology) (099)	Herzuma, Ogivri, and Ontruzant will move from preferred to non-preferred. Kanjinti and Trazimera continue to be the preferred medications in this policy. Members currently using Herzuma, Ogivri, or Ontruzant will have continued coverage so their care isn’t disrupted. Providers who request prior authorization for Herzuma, Ogivri, and Ontruzant will need to go through AIM Specialty Health.	7/1/2022
Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033) Supportive Care Treatments for Patients with Cancer (105)	Udenyca will move from preferred to non-preferred. Neulasta and Ziextenzo will move from non-preferred to preferred. Fulphila, Neulasta, and Ziextenzo will now be the preferred medications listed in these policies. Members currently using Udenyca will have continued coverage so their care isn’t disrupted.	7/1/2022

Learn More About Medications

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

Questions?

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

---

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

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

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

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

Medications No Longer Covered Starting January 1, 2022

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

Medication Class	Medication Name	Covered Alternative
Anti-Parasite Treatment	Alinia	nitazoxanide
Glaucoma Treatment	Timoptic Ocudose	betaxolol levobunolol metipranolol timolol
H. Pylori Treatment	Omeclamox	lansoprazole/amoxicillin/ clarithromycin pack Talicia
Multiple Sclerosis Treatment	Tecfidera*	dimethyl fumarate
Musculoskeletal Pain Treatment	Norgesic Forte orphenadrine/aspirin/caffeine	orphenadrine
Nerve Pain Treatment	Lyrica	pregabalin*
Phenylketonuria Treatment	Kuvan	sapropterin
Short Acting Bronchodilators	ProAir HFA ProAir RespiClick	albuterol sulfate HFA
Topical Corticosteroids	triamcinolone 0.05% ointment Trianex 0.05% ointment Tritocin 0.05% ointment	triamcinolone 0.025% cream, lotion, ointment triamcinolone 0.1% cream, lotion, ointment triamcinolone 0.5% cream, ointment

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

Medications Switching Tiers

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

Medication Class	Medication Name	2022 Tier for members with a three-tier pharmacy benefit	2022 Tier for members with a four-tier pharmacy benefit	2022 Tier for members with a five-tier pharmacy benefit	2022 Tier for members with a six-tier pharmacy benefit
		Inflammatory Conditions	Avsola*	Tier 3b	Tier 4c	Tier 5d	Tier 6e
Cimzia*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Orencia*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Orencia Clickjet*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Siliq*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Simponi*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Simponi Aria*	Tier 3g		Tier 4g	Tier 5g	Tier 6g
Bowel Evacuants	Plenvu	Tier 3g	Tier 4g	Tier 3g	Tier 4g
Diabetes – SGLT2/DPP4 Inhibitor Combinations	Trijardy XR*	Tier 2c	Tier 3d	Tier 2c	Tier 3d
Inhaled Combination Agents	Breztri* Trelegy Ellipta*	Tier 2g	Tier 3g	Tier 2g	Tier 3g
Methotrexate Autoinjectors	Otrexup*	Tier 3g	Tier 4g	Tier 5g	Tier 6g
Methotrexate Autoinjectors	Rasuvo*	Tier 3g	Tier 4g	Tier 3g	Tier 4g

*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.

Medication Class	Medication Name	Quality Care Dosing Limit per prescription
Anti-Parasite Treatment	Alinia 500 mg tablets Nitazoxanide 500 mg tablets	6 tablets
	Alinia 100 mg/5 mL suspension	180 mL
Antineoplastic Medications	Jakafi 5 mg, 10 mg, 15 mg, 20 mg, 25 mg tablets	60
	Pomalyst 1 mg, 2 mg, 3 mg, 4 mg capsules	21
	Cabometyx 20 mg, 40 mg, 60 mg tablets	30
	Tagrisso 40 mg, 80 mg tablets	30
	Verzenio 50 mg, 100 mg, 150 mg, 200 mg tablets	60
Tardive Dyskinesia Treatment	Ingrezza 40 mg-80 mg initiation pack	1 pack
	Ingrezza 40 mg, 60 mg, 80 mg capsules	30

Medical Policy Updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policies is newly prescribed for you. With step therapy, you may need to try a less expensive (lower step) medication before we’ll cover a more expensive (higher step) medication. Your doctor can request an exception if needed.
• Prior authorization. This applies if you are newly prescribed Alunbrig.

For this policy	Update
Anti-Migraine Policy (021)	Adding dihydroergotamine spray and Migranal spray to step 3 for acute migraine treatment. This will apply to members newly prescribed these medications.
Asthma and Chronic Obstructive Pulmonary Disease Medication Management (011)	Adding Trelegy Ellipta and Breztri as step 2 agents requiring the use of other covered products for Asthma/Chronic Obstructive Pulmonary Disease (COPD) to be used prior to approval. This will apply to members newly prescribed these medications.
Diabetes Step Therapy (041)	Moving Trijardy XR from step 3 to step 2 under the DPP4 and SGLT2 sections of the policy. Members with a claim history or an approved authorization don’t need to do anything, but these medications will now be covered at a lower-tier cost. New prescriptions for this medication will follow the step therapy policy.
Immune Modulating Drugs (004)	Adding Zeposia to non-preferred and requiring the use of two preferred agents prior to approval (when used to treat ulcerative colitis [UC]). This will apply to members newly prescribed these medications.
Injectable Methotrexate (Otrexup & Rasuvo) (840)	New medical policy that requires the use of generic methotrexate before we’ll approve coverage of either Otrexup or Rasuvo. Applies to new prescriptions.
Multiple Sclerosis Step Therapy (839)	New medical policy that requires the use of dimethyl fumarate or glatiramer/Glatopa before we’ll cover other agents. Applies to new prescriptions.
Oncology Drugs (409)	Requiring prior authorization for Alunbrig. Applies to new prescriptions.

Looking for More Information?

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

Questions?

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

Effective July 1, 2021, Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary

Beginning July 1, 2021, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex®´ plans* with a three-tier pharmacy benefit. As part of this update, certain medications may:

• No longer be covered (exceptions may be granted)
• Have new quantity or dosing limits
• Require prior authorization

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

Medications No Longer Covered Starting July 1, 2021

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

Medication Class		Medication Name	Covered Alternative
Migraine Treatment		Allzital 25 mg/325 mg tablets	Butalbital/Acetaminophen 25 mg/325 mg tablets
Narcotic Analgesics**		Oxycodone ER Oxycontin 10 mg tablets Oxycontin 15 mg tablets Oxycontin 20 mg tablets Oxycontin 30 mg tablets Oxycontin 40 mg tablets Oxycontin 60 mg tablets Oxycontin 80 mg tablets	Xtampza ER 9 mg capsules Xtampza ER 13.5 mg capsules Xtampza ER 18 mg capsules Xtampza ER 27 mg capsules Xtampza ER 36 mg capsules
Prenatal Vitamin		Azeschew tablets	Mynatal Mynatal Advance Mynatal Plus Prenatabs FA Prenatabs Rx Trinate
Tetracycline Antibiotic		Minocycline 50 mg tablets Minocycline 75 mg tablets Minocycline 100 mg tablets	Minocycline 50 mg capsules Minocycline 75 mg capsules Minocycline 100 mg capsules

**The covered alternatives for Narcotic Analgesics will be added to our formulary on April 1, 2021.

Medications with New Quality Care Dosing Limits

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

Medication Class		Medication Name		Quality Care Dosing Limit per prescription
Topical Antibiotic		Gentamicin 0.1% cream		30 grams
		Gentamicin 0.1% ointment		30 grams
Topical Antibiotic/Corticosteroid Combination		Iodoquinol/Hydrocortisone/Aloe gel		48 grams
Topical Antifungal		Ciclopirox 0.77% cream		90 grams
		Ciclopirox 0.77% gel		100 grams
		Ciclopirox 1% shampoo		120 mL
		Ciclopirox 0.77% topical suspension		90 mL
		Nystatin, Nyamyc, Nystop 100,000 units/gram powder		60 grams
Topical Antiviral		Denavir 1% cream		10 grams
Topical Corticosteroids		Halobetasol propionate 0.05% cream		50 grams
		Halobetasol propionate 0.05% ointment		50 grams
Topical Immunosuppresive		Pimecrolimus 1% cream		120 grams

Medications Requiring Prior Authorization

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

Medication Class
Fulphila	Granix	Nivestym
Riabni	Ruxience	Truxima
Udenyca	Zarxio	Ziextenzo

Looking for More Information?

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

Questions?

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

---

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

Effective July 1, 2021, pharmacists filling an opioid prescription will be alerted if you may be receiving a total level of opioids that’s potentially unsafe. This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex®’ plans* with a three-tier pharmacy benefit and Managed Blue for Seniors plans.

Under this safety review, when a pharmacist is filling an opioid prescription, they’ll receive a real-time alert if your total opioid dose across all opioid or opioid-containing prescriptions reaches or exceeds 90 morphine milligram equivalents (MME) per day. If the pharmacist determines the opioid dose is appropriate for care, they can fill the prescription. However, if they believe there could be a safety issue, they may choose not to fill the prescription.

If the pharmacist doesn’t fill the prescription, your prescribing doctor can contact Blue Cross to request authorization for coverage. If authorized, coverage will be approved for up to one year. However, one of the following must be true for the request to be approved:

• The member has a diagnosis of cancer.
• The member is receiving opioids as part of palliative care.
• The prescriber says that the amount of opioid prescribed is necessary for adequate pain management, based on the member’s clinical circumstances.

This safety review doesn’t apply to prescriptions written by in-network oncologists, palliative care providers, and pain management specialists.

Questions?

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

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

---

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

Effective July 1, 2021, coverage for the following medications will move out of our medical benefit and only be included under our pharmacy benefit. This change will apply to all medical plans, except Managed Blue for Seniors, group Medicare Advantage, group Medex®´, and Federal Employee Program plans.

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.

---

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 Changes to Opioid Coverage

We’re making several changes to our coverage of opioids, a class of medication that’s sometimes prescribed by doctors and providers to treat pain. Effective April 1, 2021, we’ll cover Xtampza ER. With this change, we’ll no longer cover OxyContin and Oxycodone ER, the authorized generic, as of July 1, 2021. We’ll work with prescribers to transition members to Xtampza ER, the covered alternative, when clinically appropriate. Prescribers will need to request prior authorization for Xtampza ER.

If a member needs to continue taking OxyContin or Oxycodone ER, their prescriber may request an exception if the medication is medically necessary. If the exception is approved, the member will pay the highest-tier cost.

Prescribers without Prior Authorization Must Request It before July 1, 2021

To support the safe and appropriate use of opioids, we’re expanding our Pain Management Policy. With the expansion, prescribers who don’t have an approved authorization for coverage of a member’s opioid medication must request authorization for that member’s medication before July 1, 2021. We’ll then review the request to determine if the medication is medically necessary. Prescribers who’ve already received prior authorization for a member’s opioid medication don’t need to request it again until it expires. Oncologists, palliative care providers, and pain management specialists in the Blue Cross Blue Shield of Massachusetts network are exempt from this prior authorization requirement. We’ll notify you and your prescriber if this change applies to you.

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

---

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

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

Medications No Longer Covered Starting January 1, 2021

The non-covered and covered alternatives for high-triglyceride treatments and muscle relaxants are changing. Chlorzoxazone 250 mg will no longer be a covered alternative to specific Lorzone medications and will remain non-covered. The correct medications and covered alternatives are listed below:

Medication Class	Medication Name	Covered Alternatives
High-triglyceride treatments	fenofibrate 50 mg fenofibrate 150 mg	fenofibrate 40 mg fenofibrate 43 mg fenofibrate 48 mg fenofibrate 54 mg fenofibrate 67 mg fenofibrate 120 mg fenofibrate 130 mg fenofibrate 134 mg fenofibrate 145 mg fenofibrate 160 mg fenofibrate 200 mg
Muscle relaxants	cyclobenzaprine 7.5 mg	cyclobenzaprine 5 mg cyclobenzaprine 10 mg
	Lorzone 375 mg Lorzone 750 mg	chlorzoxazone 500 mg

Medications Switching Tiers

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

Medication Class	Medication Name	2021 Tier for members with a three-tier pharmacy benefit	2021 Tier for members with a four-tier pharmacy benefit	2021 Tier for members with a five-tier pharmacy benefit	2021 Tier for members with a six-tier pharmacy benefit
High-triglyceride treatments	fenofibrate 40 mg, 43 mg, 120 mg, and 130 mg	Tier 2a	Tier 3b	Tier 2a	Tier 3b

a. This medication was previously covered at Tier 1.
b. This medication was previously covered at Tier 2.

Medications with New Quality Care Dosing Limits

Quality Care Dosing helps us ensure that the quantity and dose of certain prescription medications meet the Food and Drug Administration, manufacturer, and clinical recommendations. Two additional medications will have Quality Care Dosing limits:

Medication Class	Medication Name	Quality Care Dosing Limit per Prescription
Immunomodulators	Humira CF Pen 40 mg/0.4 ml	2 pens
	Kineret 100 mg/0.67 ml syringe	30 syringes

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

---

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

Beginning January 1, 2021, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

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

Medications No Longer Covered Starting January 1, 2021

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

Medication Class	Medication Name	Covered Alternative
Anti­histamines	Ryvent 6 mg	carbinoxamine 4 mg
Anti­hypertensive Agents	Lotrel	amlodipine/­benazepril
	Tarka	trandolapril/­verapamil
Biologic Agents	Cosentyx	Enbrel Humira Otezla Skyrizi Stelara Taltz Tremfya Xeljanz Xeljanz XR
Buprenorphine/­­Naloxone Sublingual Products	Bunavail Suboxone Zubsolv	buprenorphine/­­naxolone SL film buprenorphine/­­naxolone SL tablets
Colchicine Products	Colcrys	colchicine tablets Mitigare
Contraceptives	NuvaRing	etonogestrel/­ethinyl estradiol vaginal ring1
Cough/Cold Agents	benzonatate 150 mg	benzonatate 100 mg benzonatate 200 mg
Glaucoma Treatments	Alphagan P Azopt Betimol Betoptic S Timoptic	betaxolol brimonidine dorzolamide dorzolamide/timolol timolol
High Triglyceride Treatments	fenofibrate 50 mg fenofibrate 150 mg	fenofibrate 40 mg fenofibrate 43 mg fenofibrate 48 mg fenofibrate 54 mg fenofibrate 67 mg fenofibrate 120 mg fenofibrate 130 mg fenofibrate 134 mg fenofibrate 145 mg fenofibrate 160 mg fenofibrate 200 mg
Infertility Treatments	Chorionic Gonadotropin Pregnyl	Novarel Ovidrel
Laxatives	Kristalose 10GM packets	lactulose syrup
Muscle Relaxants	cyclobenzaprine 7.5 mg	cyclobenzaprine 5 mg cyclobenzaprine 10 mg
	Lorzone 375 mg Lorzone 750 mg	chlorzoxazone 500 mg
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)	Arthrotec 75 mg	diclofenac/­­misoprostol
	ketoprofen 25 mg	ketoprofen 50 mg ketoprofen 75 mg ketoprofen ER 200 mg
	Nalfon 400 mg Nalfon 600 mg	fenoprofen 600 mg tablets
	naproxen sodium CR 375 mg naproxen sodium CR 500 mg	naproxen 250 mg naproxen 375 mg naproxen 500 mg tablets naproxen sodium 275 mg tablets naproxen sodium 550 mg tablets
Ophthalmic Anti-Inflammatory Products	Lotemax Lotemax SM	fluorometholone loteprednol prednisolone
Oral Antibiotics	doxycycline hyclate 50 mg tablets	doxycycline hyclate 20 mg tablets doxycycline hyclate 50 mg capsules doxycycline hyclate 100 mg tablets/capsules doxycycline hyclate 150 mg tablets
Oral Diabetes Treatments	ActoPlus MET ActoPlus MET XR	pioglitazone/­­metformin
Overactive Bladder Agents	Vesicare	darifenacin ER oxybutynin oxybutynin ER solifenacin tolterodine tolterodine ER trospium trospium XR
Parkinson’s Treatments	Stalevo	carbidopa/­­levodopa/­­entacapone
Prenatal Vitamins	Azesco Trinaz	generic prenatal vitamin options1
Topical Actinic Keratosis Treatments	Carac 0.50% Zyclara 2.50% Zyclara 3.75%	fluororacil cream fluororacil solution imiquimod cream
Ulcerative Colitis Treatments	Apriso 0.375 GM	mesalamine 0.375 GM

1. These products are eligible for $0 copay with a prescription, under the Affordable Care Act.

Medications Excluded from Coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2021. You’ll be responsible for the full cost of these medications when filling a prescription at the pharmacy. This change will apply to all commercial plans, group Medex^®´plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications.

Medication Name
diclofenac 1% gel1
Niacor 500 mg2
niacin 500 mg IR2
Voltaren 1% gel1

1. This medication is available over-the-counter without a prescription.
2. Over-the-counter alternatives that don’t require a prescription are available for this medication.

Medications Switching Tiers

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

Medication Class	Medication Name	2021 Tier for members with a three-tier pharmacy benefit	2021 Tier for members with a four-tier pharmacy benefit	2021 Tier for members with a five-tier pharmacy benefit	2021 Tier for members with a six-tier pharmacy benefit
Bone Marrow Stimulants	Ziextenzo	Tier 3a	Tier 4a	Tier 5a	Tier 6a
High-Cost Generic Agents	amlodipine/­­benazepril	Tier 2b	Tier 3b	Tier 2b	Tier 3b
	carbidopa/­­­levodopa/­­­entacapone	Tier 2b	Tier 3b	Tier 2b	Tier 3b
	diclofenac/­­misoprostol	Tier 2b	Tier 3b	Tier 2b	Tier 3b
	dutasteride/­­tamsulosin	Tier 2b	Tier 3b	Tier 2b	Tier 3b
	trandolapril/­­verapamil	Tier 2b	Tier 3b	Tier 2b	Tier 3b
High triglyceride treatments	fenofibrate 40 mg, 43 mg, 120 mg, and 130 mg	Tier 2b	Tier 3c	Tier 2b	Tier 3c
Topical Antiviral Treatments	Acyclovir cream	Tier 2b	Tier 3b	Tier 2b	Tier 3b
	Acyclovir ointment	Tier 1c	Tier 1c	Tier 1c	Tier 1c

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

Medications with New Quality Care Dosing Limits

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

Medication Class	Medication Name	Quality Care Dosing Limit per prescription
Immunomodulators	Actemra 162 mg/0.9 ml syringe	4 syringes
	Actemra Actpen 162 mg/0.9 ml	4 pens
	Cimzia 200 mg vial kit	6 vials
	Cimzia 2x200 mg/ml syringe kit	2 kits
	Cimzia 2x200 mg/ml start kit	6 syringes
	Humira CF 10 mg/0.1 ml syringe	2 syringes
	Humira CF 20 mg/0.2 ml syringe	2 syringes
	Humira CF 40 mg/0.4 ml syringe	2 syringes
	Humira CF Pedi-Crohn’s 80-40 mg kit	2 syringes
	Humira CF Pedi-Crohn’s 80 mg/0.8 ml kit	2 syringes
	Humira CF Pen 40 mg/0.4 ml	2 pens
	Kineret 100 mg/0.67 ml syringe	30 syringes
	Olumiant 1 mg tablets	30 tablets
	Orencia 50 mg/0.4 ml syringe	4 syringes
	Orencia 87.5 mg/0.7 ml syringe	4 syringes
	Orencia ClickJect 125 mg/ml autoinjector	4 autoinjectors
	Orencia 250 mg vial	4 vials
	Otezla 28-day starter pack	55 tablets (1 pack)
	Rinvoq ER 15 mg tablets	30 tablets
	Stelara 45mg/0.5ml vial	1 vial
	Stelara 45 mg/0.5 ml syringe	1 syringe
	Stelara 90 mg/ml syringe	1 syringe
Topical Antiviral Treatments	acyclovir cream Zovirax cream	two tubes per prescription two tubes per prescription
Topical Corticosteroids	calcipotriene/betamethasone dipropionate ointment	120 GM
	calcipotriene/­betamethasone dipropionate scalp solution	120ml
	diflorasone 0.05% cream diflorasone 0.05% ointment	120 GM

Medications Requiring Prior Authorization

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

Medication Name
Ziextenzo1

1. Members currently filling prescriptions for this medication may continue to do so without prior authorization.

Looking for More Information?

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

Questions?

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

Effective October 1, 2020, Inflectra Is Now Preferred over Remicade for Members with Existing Prescriptions

Effective October 1, 2020, the immune-modulating medication Inflectra is now the preferred brand-name medication over Remicade. This affects members 18 years and older with existing prescriptions, and applies to prescriptions covered under the medical and pharmacy benefit.

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

Prior authorization is required for Inflectra and Remicade prescriptions.

Questions?

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

---

Sam’s Club Will Remain in Our Pharmacy Network

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

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

Questions?

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

---

Changes to Our Specialty Pharmacy Network for Fertility Medications

Beginning August 31, 2020, AcariaHealth™ Fertility will no longer participate in our specialty pharmacy network for fertility medications. This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the National Preferred Formulary (NPF).

Members will be able to complete their current course of treatment with AcariaHealth Fertility; however, specialty fertility medications purchased through AcariaHealth Fertility after August 31, 2020, will no longer be covered. We’ll contact members who fill their prescriptions at AcariaHealth Fertility to let them know that the pharmacy is leaving our specialty fertility network, and help them transition to another in-network specialty pharmacy for fertility medications. This change only applies to AcariaHealth Fertility and our specialty fertility network. AcariaHealth Fertility’s parent company, AcariaHealth, will remain in our specialty pharmacy network.

Specialty pharmacies provide specialty medications that are used to treat certain complex health conditions. For more information about specialty medications, use our Medication Lookup tool.

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

---

Upcoming Changes to the Blue Cross Blue Shield of Massachusetts Formulary, Effective October 1, 2020

Effective October 1, 2020, we're updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´* plans with a three-tier pharmacy benefit. This update includes changes that were originally scheduled to go into effect on May 1 and July 1. As part of this update, certain medications may:

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

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

Medications No Longer Covered Starting October 1, 2020

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

Medication Class	Medication Name	Covered Alternative
Acne (topical)	Differin 0.3% gel pump	Adapalene 0.3% gel
	Retin-A cream	Tretinoin cream
Acne (topical)/Psoriasis	Fabior 0.1% foam Tazorac 0.5% and 0.1% cream Tazorac 0.5% and 0.1% gel	Tazarotene
Analgesics (non-narcotic)	Tramadol ER capsules	Tramadol ER tablets
Anticonvulsants	Depakote Depakote ER Depakote Sprinkle	Divalproex Divalproex ER Divalproex Sprinkle
	Keppra	Levetiracetam Levetiracetam ER
	Lamictal Lamictal ODT Lamictal XR	Lamotrigine Lamotrigine ODT Lamotrigine XR
	Topamax	Topiramate
	Trileptal	Oxcarbazepine
	Zonegran	Zonisamide
Antidepressants	Fluoxetine tablets Venlafaxine ER tablets	Fluoxetine capsules Venlafaxine ER capsules
Antidepressants/ Nerve Pain	Savella	Duloxetine Pregabalin
Antineoplastics	Arimidex	Anastrozole
	Aromasin	Exemestane
	Gleevec	Imatinib
Aspirin Products	Duralaza	81 mg aspirin1 Over-the-counter 325 mg aspirin2
Blood Pressure	Nitro-Dur 0.1 mg/hr patch Nitro-Dur 0.2 mg/hr patch Nitro-Dur 0.3 mg/hr patch Nitro-Dur 0.4 mg/hr patch Nitro-Dur 0.6 mg/hr patch Nitro-Dur 0.8 mg/hr patch	Nitroglycerin patch
Chemotherapy/ Protective Agent	Fusilev	Levoleucovorin
Diabetes	Invokamet Invokamet XR Invokana	Farxiga Jardiance Synjardy Synjardy XR Xigduo XR
Erectile Dysfunction (oral)	Cialis3 Levitra3 Staxyn3 Stendra3 Viagra3	Sildenafil4
Irritable Bowel Syndrome Treatment	Zelnorm	Amitiza Linzess Motegrity
Migraine	Imitrex 6mg/0.5ml injection	Sumatriptan 6mg/0.5ml injection
Multiple Sclerosis Treatment	Copaxone	Glatiramer Glatopa
Ophthalmic Combinations	Tobradex Zylet	Neomycin/­Bacitracin/­Polymyxin B/Hydrocortisone, Neomycin/­Polymyxin B/Dexamethasone, Neomycin/­Polymyxin B/Hydrocortisone, Sulfacetamide/­Prednisolone, Tobramycin/­Dexamethasone
Smoking Cessation	Zyban 150 mg	Bupropion SA 150 mg
Thrombocytopenia Treatment	Mulpleta	Doptelet

1. This over-the-counter product is eligible for $0 copay with a prescription, under the Affordable Care Act.
2. This over-the-counter product is excluded from coverage. Exceptions won’t be accepted.
3. The quantity limit for this medication is 4 units per prescription, unless an exception is approved for more.
4. The quantity limit is increasing from 4 to 6 tablets per prescription on October 1, 2020.

Compounded Medications Excluded from Coverage

The following compounded medications will be excluded from our pharmacy benefit, effective October 1, 2020. If any of these medications is used as an ingredient in a compounded medication in the exact strength and form listed below, you may be responsible for the full cost of the medication. This change will apply to all medical plans, group Medex* plans with pharmacy benefits, and Managed Blue for Seniors with pharmacy benefits. Formulary exceptions won’t be accepted for these medications.

Medication Class	Medication Name	Strength and Form
Anticonvulsants	Carbamazepine	100 mg chew tablet 200 mg tablet
Antidepressants	Amitriptyline	10 mg tablets 25 mg tablets 50 mg tablets 75 mg tablets 100 mg tablets 150 mg tablets
	Clomipramine	25 mg capsules 50 mg capsules 75 mg capsules
	Imipramine Pamoate	75 mg capsules 100 mg capsules 125 mg capsules 150 mg capsules
Nitroglycerin	Nitro-Bid	2% ointment

Medications Switching Tiers

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

Medication Class	Medication Name	2020 Tier for members with a three-tier pharmacy benefit	2020 Tier for members with a four-tier pharmacy benefit	2020 Tier for members with a five-tier pharmacy benefit	2020 Tier for members with a six-tier pharmacy benefit
Erectile Dysfunction (oral)	Tadalafil	Tier 3a	Tier 4b	Tier 3a	Tier 4b
Erectile Dysfunction (oral)	Vardenafil	Tier 3a	Tier 4b	Tier 3a	Tier 4b

a. This medication was previously covered at Tier 1.
b. This medication was previously covered at Tier 2.

Medications with New Quality Care Dosing Limits

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

Medication Class	Medication Name	Quality Care Dosing Limit per prescription
Antibiotics (topical)	Clindamycin Phosphate 1% foam	100 GM
	Clindamycin Phosphate 1% gel	150 GM
	Clindamycin Phosphate 1% lotion	120 ml
	Clindamycin Phosphate 1% solution	60 ml
	Clindamycin Phosphate 2% cream	80 GM
	Mupirocin 2% cream	60 GM
	Mupirocin 2% ointment	44 GM
Anticholinergics (inhaled)	Tudorza Pressair 400 mcg inhaler	2 inhalers
	Yupelri 175 mcg/3 ml solution	30 vials
Antifungals (topical)	Econazole Nitrate 1% cream	170 GM
	Ketoconazole 2% cream	120 GM
	Ketoconazole 2% shampoo	240 ml
Antimuscarinics (inhaled)	Spiriva Handihaler 18 mcg inhaler	30 capsules
Beta Agonists (long-acting, inhaled)	Brovana 15 mcg/2 ml solution	120 ml
	Perforomist 20 mcg/2 ml solution	60 ml
Combinations (inhaled)	Stiolto RespiMat inhaler	1 inhalation cartridge (4 GM)
Corticosteroids (inhaled)	Alvesco 80 mcg inhaler	6.1 GM (1 inhaler)
	Asmanex Twisthaler 110 mcg, 220 mcg inhaler	1 inhaler
	Flovent Diskus 50 mcg, 100 mcg, 250 mcg	60 blisters
	Flovent HFA 44 mcg, 110 mcg, 220 mcg	1 inhaler
	Pulmicort Flexhaler 90 mcg inhaler	1 inhaler
	Pulmicort Flexhaler 180 mcg inhaler	2 inhalers
	Pulmicort Respule 0.25 mg/2 ml, 0.5 mg/2 ml	60 ml (30 ampules)
	Pulmicort Respule 1 mg/2 ml	30 ml (15 ampules)
	QVAR 40 mcg inhaler	10.6 GM (1 inhaler)
SSRI (Antidepressants)	Prozac 40 mg, Fluoxetine 40 mg	Limits removed1
	Zoloft 100 mg, Sertraline 100 mg

1. Quality Care Dosing limits were removed for these medications on July 1, 2020.

Medications That Now Require Step Therapy

Step Therapy is a key part of our Prior Authorization program. It enables us to help doctors provide members with an appropriate and affordable medication treatment. Before coverage is allowed for certain costly “second-step” medications, we require that members first try an effective, but less expensive, “first-step” medication. Some medications may have multiple steps.

The following medications now require Step Therapy. This change only applies to new prescriptions. Members with a claim for any of these medications within the previous 130 days can continue their therapy without interruption.

Medication Class	Step 1 Medication	Step 2 Medication	Step 3 Medication
Migraine Treatment	Naratriptan Rizatriptan Sumatriptan	Almotriptan Eletriptan Frovatriptan Sumatriptan/­Naproxen Zolmitriptan Zomig nasal spray	Amerge Axert Frova Imitrex Imitrex Injection Maxalt Maxalt MLT Relpax Treximet Zomig tablets

Looking for More Information?

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

Questions?

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

---

Coverage Update for Truvada

On July 1, 2020, we’ll begin covering Truvada, an HIV pre-exposure prophylaxis (PrEP) medication, at no additional cost for members who aren’t currently filling other HIV medications. Members taking other HIV medications, or are switching from an HIV medication to Truvada, will have to pay their usual out-of-pocket costs, including copays, co-insurance, and deductibles. This change applies to new prescriptions and refills, and to plans with either the Blue Cross Blue Shield of Massachusetts Formulary or National Preferred Formulary. However, the change doesn’t apply to grandfathered plans that don’t comply with the Affordable Care Act.

When the generic version of Truvada is released, we’ll start covering the generic version (instead of Truvada) at no additional cost for members who aren’t currently filling other HIV medications. At that time, members who continue to take Truvada, whether they’re taking additional HIV medications or not, will have to pay their usual out-of-pocket costs, including copays, co-insurance, and deductibles. 

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

---

Coverage Change for Breast Cancer Risk-Reduction Medications

On October 1, 2020, we’ll begin covering the following generic oral medications in the class of aromatase inhibitors at no additional cost for members when the medications are prescribed to reduce breast cancer risk:

• Anastrozole
• Exemestane
• Letrozole

This change applies to plans with either the Blue Cross Blue Shield of Massachusetts Formulary or the National Preferred Formulary. However, this change doesn’t apply to grandfathered plans that don’t comply with the Affordable Care Act.

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

---

Upcoming 4th-Quarter Changes to the Blue Cross Blue Shield of Massachusetts Formulary

In the fourth quarter of 2020, we're updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans with a three-tier pharmacy benefit. This update includes changes that were originally scheduled to go into effect on May 1 and July 1. As part of these updates, certain medications may:

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

 Questions?

Complete details about these changes will be available 60 days before the effective date at bluecrossma.org/disclaimer/plan-updates/pharmacy-benefit-updates. If you have any questions, please call Member Service at the number on the front of your ID card.

---

Medications That Now Require Prior Authorization, Effective April 1, 2020

Effective April 1, 2020, until further notice, the following medications will have quantity limits for first-time prescriptions for new therapies:

• Chloroquine Phosphate
• Hydroxychloroquine
• Plaquenil

If a medication is prescribed for more than 10 days, your doctor will be required to obtain Prior Authorization from us before additional medication can be covered and dispensed.

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

---

July 1st Formulary Changes Temporarily Delayed

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

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

---

May 1st Formulary Changes Temporarily Delayed

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

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

---

Upcoming changes to the Blue Cross Blue Shield of Massachusetts formulary, effective May 1,2020 - Delayed

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

• No longer be covered (exceptions may be granted)

Medications no longer covered starting May 1, 2020

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

Medication Class	Medication Name	Covered Alternative
Acne (topical)	Retin-A cream	Tretinoin cream
Antidepressants	Fluoxetine tablets Venlafaxine ER tablets	Fluoxetine capsules Venlafaxine ER capsules
Antineoplastics	Arimidex Aromasin Gleevec	Anastrozole Exemestane Imatinib
Diabetes	Invokamet Invokamet XR Invokana	Farxiga Jardiance Synjardy Synjardy XR Xigduo XR
Migraine	Imitrex 6mg/0.5ml injection	Sumatriptan 6mg/0.5ml injection
Ophthalmic combinations	Tobradex Zylet	Neomycin/Bacitracin/ Polymyxin B/Hydrocortisone, Neomycin/ Polymyxin B/ Dexamethasone, Neomycin/ Polymyxin B/Hydrocortisone, Sulfacetamide/Prednisolone, Tobramycin/Dexamethasone

Questions?

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

---

Changes to our speciality pharmacy network

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

Unless you have Medicare Advantage with a Part D plan, you’ll no longer be covered for specialty medications purchased through BriovaRx. We’ll contact members who fill their prescriptions at BriovaRx to let them know that the pharmacy has left our network, and help them transition to an in-network specialty pharmacy.

Specialty pharmacies provide specialty medications that are used to treat certain complex health conditions. For more information about specialty medications, use the Medication Lookup tool.

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

---

Changes to your prescription coverage

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

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

---

Medications no longer covered in 2020

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

Medication Class	Medication Name	Covered Alternative
Epinephrine Injections	Adrenaclick (Authorized Generic Product)	Epinephrine Auto-Injector EpiPen Auto-Injector
Inhaled Anticholinergic for chronic obstructive pulmonary disease	Tudorza inhaler	Spiriva RespiMat  Spiriva HandiHaler
Laxative	Lactulose 10 gm packet	Lactulose syrup
Stimulants	Strattera*	Atomoxetine
Nonsteroidal Anti-Inflammatory	Fenoprofen 200 mg and 400 mg capsules	Fenoprofen 600 mg tablets
Ophthalmic Dry eye Treatment	Restasis MultiDose	Restasis Single Use vials (requires prior authorization)
Oral Acne Treatment	Doxycycline IR-DR	Doxycycline Hyclate Doxycycline Monohydrate
Oral Antihistamine	Carbinoxamine 6 mg tablets	Carbinoxamine 4 mg tablets
Oral Muscle Relaxants	Chlorzoxazone 250 mg, 375 mg, and 750 mg tablets	Chlorzoxazone 500 mg tablets
Topical Acne Treatment	Aktipak gel pouch	Erythromycin/Benzoyl Peroxide
Topical Vitamin D	Sorilux Foam	Calcipotriene Cream
Weight Loss	Belviq Belviq XR	Saxenda Contrave ER

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

---

Medications excluded from coverage

The following medications will be excluded from our pharmacy benefit as of January 1, 2020. You’ll be responsible for the full cost of these medications when filling a prescription at the pharmacy. This change will apply to all commercial plans, group Medex^®'plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications

Medication or Supply Name

• Bensal HP¹
• Epiduo¹
• Pliaglis²
• Prilocaine 7%/Tetracaine 7%²
• Sil-k 2” X 5” Pad³

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

---

Medications switching tiers

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

Medication Class	Medication Name	2020 Tier for members with a three-tier pharmacy benefit	2020 Tier for members with a four-tier pharmacy benefit	2020 Tier for members with a five-tier pharmacy benefit	2020 Tier for members with a six-tier pharmacy benefit
Topical Antiviral	Acyclovir Ointment	Tier 2a	Tier 3b	Tier 2a	Tier 3b
Granulocyte Stimulating Factor	Nivestym	Tier 3b	Tier 4c	Tier 5d	Tier 6e

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

---

Medications with new quality care dosing limits

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

Medication Name	Quality Care Dosing Limit per prescription
Calcipotriene 0.0005% cream, ointment, topical solution  Dovonex 0.0005% cream, ointment, topical solution	180 gm (all formulations)
Doxepin 5% cream  Prudoxin 5% cream Zonalon 5% cream	90 gm total
Albuterol HFA authorized products  ProAir HFA  ProAir RespiClick  Ventolin HFA  Proventil HFA  Xoponex HFA	2 inhalers
Oxiconazole nitrate 1% cream Oxistat cream	90 gm each
Triamcinolone 0.147mg/spray aerosol Kenalog aerosol (T3)	2 aerosol cans (126 gm)

---

Expanded access to certain cholesterol medications

In 2020, you’ll be able to fill prescriptions for Praluent and Repatha at any retail pharmacy that has access to these medications in the Express Scripts^®' network.* Previously, these medications, which are known as PCSK9 agents and are typically used to lower cholesterol levels, were only available through in-network specialty pharmacies.

*Please note that these medications may not be available at all pharmacies.

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

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

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

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

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

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

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

---

National Prescription Drug Take Back Day is October 26, 2019

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

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

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

---

Changes to our speciality pharmacy network and medication list

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

AllianceRx Walgreens Prime will leave our retail specialty pharmacy fertility network

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

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

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

Updates to our specialty pharmacy medication list

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

Medications now available through our specialty pharmacy network:

• Cinryze
• Haegarda
• Berinert
• Kalbitor
• Ruconest

New-to-market medications:

Questions?

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

---

Introducing our new Medication Lookup Tool

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

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

View medications by tier*

To use the tool, go to Medication Lookup tool.

Questions?

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

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

---

Coming in July 2019: upcoming changes to our pharmacy program

Beginning July 1, 2019, we’re making changes to our list of covered medications for medical plans with pharmacy benefits, as well as Medex^® plans with a three-tier pharmacy benefit. We’ll notify impacted members by June 1, 2019. As part of these updates, certain medications may:

• No longer be covered
• Switch cost tiers
• Be excluded from pharmacy benefit coverage due to over-the-counter availability
• Require prior authorization

Certain medication will become non-covered

After a careful review of its cost and covered alternatives, we’ve decided to remove the medication in the table below from our list of covered medications, effective July 1, 2019. Your doctor or prescriber may request a coverage exception if the medication is medically necessary. If the request is approved, you’ll pay the highest-tier cost for the medication.

Medication Class	Medication Name	Covered Alternative
Erythropoietins	Procrit*	Retacrit

*If you’re currently prescribed to Procrit, you may continue to fill your prescription under your existing prior authorization. However, you’ll pay more as the medication will move to the highest tier.

Medications that are switching tiers

When the cost of a medication changes, we may move the medication to a different tier. The medications listed below are moving to a higher tier, which means they may cost you more.

Medication Class	Medication Name	2019 Tier For members with a three-tier pharmacy benefit	2019 Tier For members with a four-tier pharmacy benefit	2019 Tier For members with a five-tier pharmacy benefit	2019 Tier For members with a six-tier pharmacy benefit
Topical Testosterone		Tier 3a	Tier 4b	Tier 3a	Tier 4b
Granulocyte Stimulant Factor		Tier 3a	Tier 4b	Tier 5c	Tier 6d

^a This medication was previously covered at Tier 2.
^b This medication was previously covered at Tier 3.
^c This medication was previously covered at Tier 4.
^d This medication was previously covered at Tier 5.

Medications excluded from pharmacy benefit coverage

The following medications will be excluded from our pharmacy benefit due to over-the-counter availability. This change will apply to all commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exceptions won’t be accepted for these medications.

Medication Name

• Differin 0.1% (All topical forms)
• Adapalene 0.1% (All topical forms)
• Proton pump inhibitors when included as part of a compounded medication*

*Members under the age of 18 will still be covered for these medications. However, prior authorization will be required for new prescriptions.

Medications requiring prior authorization

For certain medications, your doctor must first obtain approval before we cover it. The following medications will require prior authorization:

• Axiron*
• AndroGel*
• Berinert
• Firazyr
• Gilotrif*
• Haegarda
• Iressa*
• Kalbitor
• Neulasta
• Neupogen
• Ruconest
• Tarceva*
• Tagrisso*

*If you’re currently prescribed to this medication, you may continue to fill your prescription and won’t require prior authorization.

---

Updates to our prior authorization requirements

Beginning July 1, 2019, our prior authorization requirements for the medications listed below are changing for members with our HMO, Access Blue, and Blue Choice^® plans.

Medication Name	AdministrationBerinert
Berinert Cinqair Fasenra Firazyr Haegarda Kalbitor Neulasta Neupogen Nucala Ruconest	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 and dialysis setting

This change doesn’t affect these medications when administered in inpatient care, surgical day care, urgent care centers, and emergency room settings.

Upcoming changes to our pharmacy program

Beginning January 1, 2019, we're making changes to our list of covered medications for medical plans with pharmacy benefits, as well as Medex® plans with a three-tier pharmacy benefit. As part of these updates, certain medications may:

• No longer be covered
• Switch tiers
• Have a new dosing limit
• Require prior authorization
• Change cost

Proton pump inhibitors no longer a covered benefit in 2019

Effective January 1, 2019, proton pump inhibitors (medications commonly used to reduce stomach acid) will be excluded from your pharmacy benefit, except for members under the age of 18.

• This benefit exclusion will apply to members 18 years of age and older who currently have pharmacy benefits.
• This benefit exclusion will not apply to members under the age of 18.
• This benefit exclusion will not apply to members being treated with combination prescription medications to treat Helicobacter pylori (H. pylori).

Exceptions will no longer be available for this class of medications, even if the member has a prescription or if we've covered it in the past.

Members should talk to their doctors about over-the-counter medication options that are available without a prescription.

This affects the following medications:

• Aciphex
• First-Lansoprazole
• Omeprazole sodium bicarbonate
• Rabeprazole
• Aciphex Sprinkle
• First-Omeprazole
• Pantoprazole
• Zegerid
• Dexilant
• Lansoprazole
• Prevacid
• Esomeprazole magnesium
• Nexium
• Prilosec
• Esomeprazole strontium
• Omeprazole
• Protonix

Medications no longer covered in 2019

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

Medication Class	Non-Covered Medication or Supply	Covered Alternative
Anticoagulants (medications to treat and prevent blood clots)	Pradaxa*	Eliquis, Xarelto, warfarin
Colchicine Products (medications to treat gout)	Single-source colchicine products (colchicine products that resemble generic versions in name only)	Colcrys, Mitigare
Dopamine Agonists (treatment for Parkinson's disease)	Mirapex	ropinirole, pramipexole
Glucagon-Like Peptide 1 Agonists (injectable medications to treat diabetes)	Victoza	Byetta, Bydureon, Trulicity
Granulocyte Stimulants (white blood cell replacement agents used during chemotherapy)	Neupogen**††	Zarxio††, Granix††
Ophthalmic Anti-Inflammatory (short-term medications to treat inflammation in the eye)	FML S.O.P., FML Liquifilm, Pred Mild, Maxidex, Flarex	Lotemax, generic ophthalmic steroid medications

*Members currently using Pradaxa will be given an exception to continue their coverage until December 31, 2019, but they'll pay the highest-tier cost since the medication will no longer be covered.
**Members currently using Neupogen will be given an exception to continue their coverage until May 31, 2019, but they'll pay the highest-tier cost since the medication will no longer be covered.
^††This medication must be filled at an in-network retail specialty pharmacy.

Medications that are switching tiers

When the cost of a medication changes, we may move the medication to a different tier. Depending on the tier change, your payment for the following medications may increase or decrease:

These medications are moving to a higher tier, which means they may cost you more.

Medication Class	Medication Name	2019 Tier (for members with a three-tier pharmacy benefit)	2019 Tier (for members with a four-tier pharmacy benefit)	2019 Tier (for members with a five-tier pharmacy benefit)	2019 Tier (for members with a six-tier pharmacy benefit)
Infliximab Products (immunosuppressive medications to treat psoriasis, rheumatoid arthritis, Crohn's disease, etc.)	Remicade†† Renflexis††	Tier 3a	Tier 4b	Tier 5c	Tier 6d
Multiple Sclerosis: Oral Agents	Aubagio††	Tier 3a	Tier 4b	Tier 5c	Tier 6d

These medications are moving to a lower tier, which means they may cost you less.

Medication Class	Medication Name	2019 Tier (for members with a three-tier pharmacy benefit)	2019 Tier (for members with a four-tier pharmacy benefit)	2019 Tier (for members with a five-tier pharmacy benefit)	2019 Tier (for members with a six-tier pharmacy benefit)
DPP4/SGLT2 Inhibitor Combinations (oral medications to treat diabetes)	Glyxambi	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Insulins - Basal	Basaglar	Tier 2e	Tier 3e	Tier 2e	Tier 3e
Multiple Sclerosis: Beta-Interferons	Plegridy††	Tier 2e	Tier 3e	Tier 4e	Tier 5e
Novel Psychotropics: Long Acting (medications to treat psychological disorders)	Abilify- Maintena	Tier 2e	Tier 3e	Tier 2e	Tier 3

^a This medication was previously covered at Tier 2.
^b This medication was previously covered at Tier 3.
^c This medication was previously covered at Tier 4.
^d This medication was previously covered at Tier 5.
^e This medication wasn't previously covered.
^†† This medication must be filled at an in-network retail specialty pharmacy.

Medications with new Quality Care Dosing Limit

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

Medication Name	Quality Care Dosing Limit
Morphabond ER 60mg	60 per prescription
Morphabond ER 100mg	30 per prescription

Medications requiring prior authorization (for new prescriptions only)

Your doctor is required to obtain prior authorization before we'll cover certain medications. The following medications will require prior authorization for new prescriptions in 2019. Members currently taking the medications will be given an exception and won't need prior authorization:

• Breo Ellipt

Higher costs for medications with supplies longer than 30 days

The cost for the medications listed below is increasing. These medications are usually dispensed in a supply longer than 30 days. We've typically only charged members a 30-day copayment for these medications. Beginning January 1, 2019, members will have to pay an adjusted copayment based on the supply length.^†

For example: if your copayment is $25 for a 30-day supply, you'll pay $75 for a 90-day supply.

• fluphenazine decanoate
• Lupron Depot Pediatric^††
• Eligard^††
• Zoladex^††
• leuprolide acetate^††
• haldol decanoate
• Lupron Depot^††
• haloperidol decanoate

^† This change only applies to members with a prescription plan that uses a copayment.

^†† This medication must be filled at an in-network retail specialty pharmacy.

How to save money for long-term prescriptions

You may be able to save money for long-term medications, also known as maintenance medications, when you order prescriptions through our mail order pharmacy. Learn more at MyBlue, or get started online by visiting Express Scripts^®, an independent company that manages your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts. You can also call them directly at 1-800-892-5119.

Questions about your treatment options

If these changes affect you and you have questions about your treatment options, such as whether a less expensive medication is available, please talk to your doctor.

---

New changes to our speciality pharmacy network

Effective September 1, 2018, we'll be making the following changes to our specialty pharmacy network:

• BriovaRx^®will join.
• AllianceRx Walgreens Prime will leave, but will remain within our fertility network.
• AllCare Plus Pharmacy and On co360 will also leave.

If you fill your prescription at one of the pharmacies that will be leaving our network, you'll receive a letter from us by August 1 to help you transition to an in-network pharmacy.

Specialty pharmacies provide medications that are used to treat certain complex health conditions. 

Questions?

If you have any questions or need help transitioning to an in-network pharmacy, please call Member Service at the number on the front of your ID card.

---

Upcoming changes to our specialty pharmacy network

Beginning September 1, 2018, we’re making changes to our specialty pharmacy network. As part of these changes AllCare Plus Specialty Pharmacy and On co360 will be leaving the network. Prescriptions for specialty medications from AllCare Plus and On co360 will no longer be covered. If you fill your prescription at either of these pharmacies, we’ll contact you by August 1, 2018 to help you transition to an in-network specialty pharmacy. Specialty pharmacies provide medications that are used to treat certain complex health conditions. You can view our Specialty Medications list.

---

Introducing Diabetes Care Value, a new way to engage and support members with diabetes

We're excited to introduce Diabetes Care Value, our newest program to support members with diabetes who are over 18. This program helps members regularly monitor blood glucose levels and manage diabetes medications, and offers incentives for making healthy choices. Beginning July 1, 2018, eligible members will receive communications in the mail from our partners, Express Scripts® and Mango Health*, with instructions on how to enroll.

The Diabetes Care Value program features:

• Tracking and monitoring of blood glucose readings with a OneTouch Verio Flex® meter, available at no additional cost. This meter pairs with the OneTouch Reveal® mobile app to track blood glucose readings.
• Access to specially trained pharmacists who monitor glucose readings through the OneTouch Reveal app and provide tailored coaching when issues are identified over time.
• Rewards and incentives for staying on track with diabetes medications and making healthy choices through Mango Health, a medication management app. Available at no additional cost, Mango Health is IOS and Android compatible.

Questions? Contact Express Scripts at 855-723-6099 and ask to speak to a pharmacist specializing in diabetes.

*Express Scripts and Mango Health are independent companies, working on behalf of Blue Cross Blue Shield of Massachusetts.

---

Update regarding changes to continuous glucose monitor sensor coverage

In March, we featured an article in our Direct to You newsletter and online on our MyBlue^® Pharmacy Updates page stating that beginning July 1, 2018, we would provide coverage for continuous glucose monitor (CGM) sensors under the Durable Medical Equipment (DME) benefit.

We have decided that coverage for CGM sensors will remain unchanged. As a result, CGM sensors will continue to be covered by your medical plan's pharmacy benefit.

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

You can refer to the original change announcement below.

---

Changes to continuous glucose monitor sensor coverage

Beginning July 1, 2018, we'll provide coverage for continuous glucose monitors (CGMs) sensors under the Durable Medical Equipment (DME) benefit. Previously, CGM sensors were covered under the pharmacy benefit.

The move to DME was made, in part, to ease confusion regarding coverage requirements for the CGM sensors. If you don't have pharmacy coverage but already have coverage for the CGM sensors under DME benefits, there's no change to your plan.

We will notify impacted members of this change by letter prior to June 1, 2018.

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

---

New prior authorization requirements for HMO, Access Blue, and Blue Choice®plans

Beginning July 1, 2018, prior authorization is required for the medications listed below when administered:

• In a doctor's office
• By home health care providers
• By home infusion therapy providers
• In outpatient hospital and dialysis settings

This change doesn't affect these medications when used in inpatient, surgical day care, urgent care centers, and ER settings. We encourage you to discuss this change with your health care provider.

Medications that require prior authorization:

• Cosentyx
• Hemlibra
• Inflectra
• Kevzara
• Rebinyn
• Renflexis
• Siliq
• Taltz
• Tremfya
• Tretten

---

Coming in July 2018: changes to our pharmacy program

Beginning July 1, 2018, we're making changes to our covered medications list for medical plans with pharmacy benefits, and Medex®plans with the three-tier pharmacy benefit. As part of these updates, certain medications will do one of the following:

• Switch tiers
• No longer be covered
• Have a new dosing limit

---

Medications that are switching tiers

When the cost of a medication changes, we move the medication to a different tier. Depending on the tier change, your payment for the following medications may increase or decrease:

Medication Class	Medication Name	New Tier as of July 1, 2018 (applies to members with a 3-tier or 5-tier pharmacy benefit)	New Tier as of July 1, 2018 (applies to members with a 4-tier or 6-tier pharmacy benefit)
Dermatological	Doxepin cream	Tier 21	Tier 32
Inhaled combination for chronic obstructive pulmonary disease	Tier Anoro Ellipta	Tier 21	Tier 32

¹ This medication was previously covered at Tier 1.
² This medication was previously covered at Tier 2.

---

Medications no longer covered

After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list. However, when these medications are medically necessary, your prescribing doctor may request a coverage exception.

Medication Class	Non-Covered Medication or Supply	Covered Alternative
Multi-Source Brands	Provigil Lidoderm Patch	Modafinil Lidocaine Patch

---

Medications with a new Quality Care Dosing Limit

To make sure that the quantity and dose of a medication meets the Federal Drug Administration, manufacturer, and clinical recommendations, we’re adding a Quality Care Dosing Limit to the following medications:

For This Medication	The Quality Care Dosing Limit for Each Prescription	Additional Information
Naloxone Carpuject (vial and syringes)	Two per 30 days	This medication will also be available at no cost for eligible members. If you have a Saver plan, the deductible will apply first. Please call Member Service at the number on your ID card, or check your benefit materials to see if you're eligible.
Narcan nasal spray	Two per 30 day
Evzio	Two per 30 day	N/A

Proton pump inhibitors to be excluded from pharmacy coverage in 2019

Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. Pylori.

This change applies to the following plans with pharmacy benefits:

• Individual plans
• Massachusetts Health Connector plans
• Medex plans with 3-tier pharmacy benefits

Walgreens Specialty Pharmacy Is Now AllianceRx Walgreens Prime

One of the specialty pharmacies in our retail network, Walgreens Specialty Pharmacy, has changed its name to AllianceRx Walgreens Prime. AllianceRx Walgreens Prime delivers specialty pharmacy services to individuals with complex medical conditions.

If you're already using this specialty pharmacy for any medication, no action on your part is required. AllianceRx Walgreens Prime will continue to fill prescriptions—just under its new name. Phone and fax numbers remain the same for now, but the website has been updated to reflect the name change.

How to reach AllianceRx Walgreens Prime:

Phone: 1-800-424-9002

Fax: 1-800-874-9179

Web: alliancerxwp.com

$0 Copay for some statin medications starting December 1, 2017

Pharmacy benefit update for statins, effective December 1, 2017

To comply with the Affordable Care Act, starting December 1, 2017, the following statin medications will be covered at no cost* for members that meet the conditions listed below.

• Atorvastatin 10-20 mg
• Fluvastatin IR and XL 20-80 mg
• Lovastatin 10-40 mg
• Pravastatin 10-80 mg
• Rosuvastatin 5-10 mg
• Simvastatin 5-40 mg

Members must meet the following criteria:

• No history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke)
• Meet the age requirement (40 to 75)
• Have one or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking)
• Have a calculated 10-year risk of a cardiovascular event of 10% or greater

Questions?

If you have any questions, please call Member Service at the number on the front of your Blue Cross ID card. For more information about your prescription coverage, visit bluecrossma.com/pharmacy. *For qualified members.

---

Pharmacy program changes coming in 2018

Beginning January 1, 2018, we're making changes to our covered medications list for medical plans with pharmacy benefits, and Medex® plans with the three-tier pharmacy benefit.

These changes affect:

• Medication coverage
• Medication dosing limits

---

Medications no longer covered as of 2018

After reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications. However, when these medications are medically necessary, a member's doctor or prescriber may request a coverage exception; if approved, the medication will process at the highest tier

Medication Class	Non-Covered Medication or Supply	Covered Alternative
Biguanides for Diabetes	Generic Metformin Film Coated ER version of Fortamet	Metformin 500mg, 850mg, 1000mg(Generic version of Glucophage) Metformin ER 500mg, 750mg (Generic version of Glucophage XR)
Estrogen and Estrogen Modifiers	Femring	Estrace Estring Premarin
Glucagon-Like Peptide-1 Agents	Tanzeum*	Bydureon Byetta Trulicity
Novel Psychotropics	Abilify Geodon Seroquel Zyprexa Zyprexa Zidis	aripiprazole ziprasidone quetiapine olanzapine olanzapine ODT

*Existing users may continue to fill this medication but will experience a tier change.

---

Medication with new Quality Care Dosing Limit

To make sure that the quantity and dose of a medication meets the Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing Limit to the following medications:

Medication Name	Quality Care Dosing Limit
Humira Pediatric Crohn's Starter Pack	1 Pack (2 Syringes)

*This impacts new starts only. There will be no impacted member communications

---

Proton pump inhibitors will be excluded from pharmacy coverage

Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. pylori.

This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We will notify impacted members beginning in November 2018 prior to the change.

---

AllCare Plus Specialty Pharmacy is joining our network

This summer you'll have another retail specialty pharmacy option where you can fill prescriptions for specialty medications. Starting July 1, 2017, AllCare Plus Pharmacy is joining our retail specialty pharmacy network. Specialty pharmacies provide medications that are used to treat certain health conditions. These medications must be filled at a retail specialty pharmacy in our network. You can view our Specialty Medications List here. We're updating this list on July 1 to include the medications AllCare Plus fills. You can reach AllCare Plus at 1-855-880-1091 or allcarepluspharmacy.com.

---

Proton pump inhibitors will be excluded from pharmacy coverage

Beginning January 1, 2019, all proton pump inhibitors will be excluded from our pharmacy benefit coverage, except for members under the age of 18 and those taking combination medications to treat H. Pylori. Formulary exceptions, including those previously approved, will no longer be available for this class of medication, except for members under the age of 18 and those taking combination medications to treat H. pylori. This change applies to all commercial plans, group Medex plans with three-tier pharmacy benefits, and Managed Blue for Seniors plans. We're making this change because several products in this class are available over the counter.

---

New prior authorization requirements for HMO, Access Blue, and Blue Choice plans

Beginning September 1, 2017, prior authorization is required for the medications listed below when administered:

• In doctor offices
• By home health care providers
• By home infusion therapy providers
• In outpatient hospital and dialysis settings

This change doesn't affect these medications when used in inpatient, surgical day care, urgent care centers, and ER settings. We encourage you to discuss this change with your health care provider.

Medications that require prior authorization:

• Egrifta
• Exondys-51
• Gel-Syn
• Ixinity
• Kanuma
• Kovaltry
• Lemtrada
• NovoEight
• Obizur
• Spinraza
• Zomacton

---

Changes to our pharmacy program

Beginning September 1, 2017, we're making changes to our covered medications list that will affect:

• Medications switching tiers
• Medications that are no longer covered
• One medication moving to benefit exclusion (also impacts Managed Blue for Seniors)

Plans affected by the changes:

• Commercial medical plans with pharmacy benefits
• Medex^® plans with the three-tier pharmacy benefit

---

Medications changing tier status

When the cost of a medication changes, we move the medication to a different tier. Depending on the tier change, you may be required to pay more or less for the following medications: Note:

Medication Class	Medication Name	Covered Tier Level as of September 1, 2017 under a 3 Tier Formulary	Covered Tier Level as of September 1, 2017 under a 4 Tier Formulary
Proton Pump Inhibitors (PPI)	Esomeprazole Lansoprazole Omeprazole Omeprazole/​BiCarb Pantoprazole Rabeprazole Prevacid SoluTab	Tier 3	Tier 4
Syringes	Terumo Thinpro Ulticare	Tier 2	Tier 3

If you're using combination prescription medications to treat H. pylori, you'll continue to pay your current cost.

---

Medications no longer covered

After carefully reviewing each medication's cost and covered alternatives, we've removed the medications listed in the chart below from our covered medications list for the plans referenced above. However, when these medications are medically necessary, your doctor or prescriber may request a coverage exception.

Medication Class	Non-Covered Medication or Supply
Angiotensin II Receptor Blockers (for high blood pressure)	Azor, Benicar, Benicar HCT, and Tribenzor
Antipsychotic Medications	Seroquel XR
Asthma/Allergy Treatment	Singulair
Cholesterol-Lowering Medications	Zetia
Colonoscopy Preparation/ Laxatives	Osmoprep*
Dermatological Treatments	Alcortin-A, Anusol HC Suppository, Lidocaine-HC 2%-2.5% Kit, Relador Pak, Relador Pak Plus, Salicylic Acid 6% Lotion Kit

*Since Osmoprep is a one-time use medication, we will not issue member letters.

---

Medication excluded from pharmacy coverage

The following medication will be excluded from our pharmacy coverage because it's cosmetic. This change will apply to all commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for Seniors. Formulary exception will not be accepted for this medication

• Medication Name
• Avenova Lid-Lash Spray