LET’S BEAT FLU. AGAIN!
Get your no-cost1 flu shot! If you haven’t gotten your flu shot yet, now’s the time. It will help protect you and everyone around you from getting sick, especially young children and the elderly who are the most at risk. All the work that we put in during the last flu season—record flu shots, hand-washing, social-distancing, and mask-wearing—really paid off, leading to the fewest flu cases ever. Let’s keep this going!
The Flu Shot Is Safe2 and Effective, and No Cost to You
The flu vaccine is available at no additional cost from in-network providers like pharmacies, limited service clinics, and community health centers. You can also get the vaccine at no additional cost from your doctor if you have an upcoming appointment. To find a location near you, visit vaccines.gov.
Learn More
To learn more about the flu shot and how to avoid getting the flu, visit our flu page.
1. Flu vaccines recommended by the Centers for Disease Control and Prevention (CDC) are covered in full when administered by an in-network provider. Exceptions may apply. Check plan materials for details.
2. Centers for Disease Control and Prevention, “Influenza (Flu) Vaccine Safety,” August 26, 2021.
Update on Coverage Change for Infused, Injectable Medications Under the Medical Benefit, Effective January 1, 2022
We previously notified you that we planned to change the covered sites of service where your infused or injectable medications are administered. We’ve decided to make Site of Care a voluntary program rather than a requirement.
Voluntary Site of Care Program
The Voluntary Site of Care Program is designed to promote the use of infused and injected medications in the most cost-effective, clinically appropriate setting. Making this a voluntary program gives you a choice of where you receive your care.
We believe that our Voluntary Site of Care Program is clinically sound, safe, and cost-effective for most of our members, and that other health risks are mitigated when care is provided at alternate sites.
What This Means for You
If you:
- Receive one of the medications listed below, we continue to require prior authorization when the medication is covered under your medical benefits.
- Would like to have your medication infused or injected at an alternate site, such as through an in-home service, you can work with your doctor to transfer your care to a home infusion therapy provider in our network, if it’s clinically appropriate and with an approved authorization. We’re working with our home infusion therapy providers to make this a smooth transition for you.
| Medications That Currently Require Prior Authorization |
|---|
| Aralast | Lemtrada |
| Berinert | Onpattro |
| Cerezyme | Prolastin |
| Cinqair | Ruconest |
| Cinryze | Soliris |
| Elelyso | Tysabri |
| Entyvio | Ultomiris |
| Exondys 51 | Uplizna |
| Givlaari | Viltepso |
| Glassia | VPRIV |
| Haegarda | Vyepti |
| Ilumya | Vyondys 53 |
| Kalbitor | Xolair |
| Kanuma | Zemaira |
What This Means for Your Coverage
The Voluntary Site of Care Program applies to all medical plans except for the following plan types:
- - Federal Employee Program
- - Indemnity
- - Managed Blue for Seniors
- - Medex®´
- - Medicare Advantage
If you have any questions, call Team Blue at the Member Service number on your ID card.
Effective January 1, 2022, Coverage Changes for Infused or Injectable Medications Under the Medical Benefit
Blue Cross Blue Shield of Massachusetts is committed to covering infused or injected medications under the medical benefit for our members in the most cost-effective, clinically appropriate setting. We previously communicated that we would implement coverage changes for infused or injectable medications under the medical benefit on September 1, 2021. Blue Cross has decided to delay the implementation of this coverage change until January 1, 2022. We will provide updates to our members prior to the new implementation date, as appropriate. There is no further action needed for members who have already received prior authorization for their infused or injectable medication, or transitioned their care. Members and providers may also choose to initiate a request before the new effective date.
Upcoming Coverage Changes for Infused or Injectable Medications Under the Medical Benefit - DELAYED TO JANUARY 1, 2022
Effective September 1, 2021, we’re changing the covered sites of service where you can get infused or injectable medications administered. We’re also requiring prior authorization for these sites, as well as the medications listed below. These changes ensure that members are receiving care in clinically-appropriate, cost-effective settings.
Where to Get Infused or Injectable Medications
Starting September 1, 2021, infused or injectable medications will be covered at the following sites of service and require prior authorization:
- Doctor’s office
- Ambulatory infusion site
- Home infusion therapy provider. For more details, please see the Site of Care - Home Infusion Therapy Member Fact Sheet.
Infused or Injectable Medications That Require Prior Authorization
The following medications will require prior authorization when they’re administered in one of the sites of service listed above. These medications will require prior authorization in order to be covered. If prior authorization is already in place, your doctor won’t need to submit a new request until the current authorization expires.
| Medications That Currently Require Prior Authorization* | Additional Medications That Will Require Prior Authorization Starting September 1, 2021 |
|---|
| Aralast | Lemtrada | Aldurazyme |
| Berinert | Onpattro | Benlysta |
| Cerezyme | Prolastin | Crysvita |
| Cinqair | Ruconest | Duopa |
| Cinryze | Soliris | Elaprase |
| Elelyso | Tysabri | Fabrazyme |
| Entyvio | Ultomoris | Krystexxa |
| Exondys 51 | Uplinza | Lumizyme |
| Givlaari | Viltepso | Naglazyme |
| Glassia | VPRIV | Ocrevus |
| Haegarda | Vyepti | Radicava |
| Ilumya | Vyondys 53 | Vimizim |
| Kalbitor | Xolair | |
| Kanuma | Zemaira | |
*Additional clinical criteria must be met to receive coverage for these medications.
What This Means for Your Coverage
As a result of these changes, members receiving infused or injectable medications may need to change where they get them to maintain coverage after September 1. If your prescribing doctor determines that treatment must be done in an outpatient hospital setting, they can contact us to request an exception.
| Members Without Prior Authorization | Members With Prior Authorization |
|---|
- If you’re receiving infused or injectable medications in an outpatient hospital setting and don’t have prior authorization on file, you must switch to one of the covered sites listed above and your doctor must request prior authorization to maintain coverage.
- If you’re currently receiving infused or injectable medications at a covered site listed above but don’t have prior authorization on file, your doctor must request prior authorization to maintain coverage.
| - If you’re currently receiving infused or injectable medications and have prior authorization on file, you may complete your approved course of treatment.
- To maintain coverage for these medications after the current approved course ends, your doctor must request a new authorization.
|
| We’ll contact impacted members in advance to help transition them to a covered site of service. | We’ll reach out to these impacted members to let them know about this change. |
This change will apply to all medical plans except for the following plan types:
- Federal Employee Program
- Indemnity
- Managed Blue for Seniors
- Medex®´
- Medicare Advantage
If you have any questions, please call Team Blue at the Member Service number on your ID card.
Changes to your telehealth benefit.
Starting on July 1, 2021, we will reinstate standard member costs for non-COVID medical- and mental-telehealth visits. How much you will pay depends on your health plan’s benefits. Medicare members are excluded from this change. The Federal Employee Program (FEP) follows guidelines from the Blue Cross Blue Shield Association regarding coverage for Federal Employee Program members. For more details, please see fepblue.org.
Since March 2020, we voluntarily and temporarily waived member costs for non-COVID telehealth visits to help ensure member access to health care services and to help prevent COVID-19 infection and illness. With the successful roll out of vaccines and the re-opening of states and businesses, this accommodation will end on July 1, 2021.
We will continue to waive costs for covered COVID-19 telehealth services as well as for COVID-19 in-person services when applicable. This includes COVID-19 vaccines.
New Prior Authorization Requirements for Select Medications Under the Medical Benefit
Starting July 1, 2021, the medications below are being added to our utilization management program, and will require your doctor to get prior authorization from us before the medications will be covered by your health plan. Prior authorization for these medications is required when administered in the following outpatient settings:
- Doctor’s office
- Home health care provider
- Home infusion therapy provider (if prior authorization is in place, no additional authorization is required until the member’s existing authorization expires)
- Outpatient hospital and dialysis settings
| Medications That Require Prior Authorization |
|---|
| Mvasi | Riabni | Ruxience | Truxima | Zirabev |
When these medications are prescribed for oncology treatment, they must be submitted through the Quality Care Cancer Program, which launches July 1, 2021. When prescribed for non-oncology use, these medications will be subject to the current prior authorization process.
This change doesn’t affect these medications in inpatient, surgical day care, urgent care centers, and emergency department settings. It also doesn’t apply to Indemnity, Managed Blue for Seniors, group Medicare Advantage, group Medex®´, and Federal Employee Program members.*
*Check your plan details for your plan’s utilization management requirements, if applicable.
For more information, call Team Blue at the Member Service number on your ID card.
Coverage for Certain Infused Oncology Medications Moving to the Medical Benefit
Effective July 1, 2021, the infused oncology medications listed below will only be covered under our medical benefit through the Quality Care Cancer Program and will require prior authorization. These medications will no longer be included in our pharmacy benefit.
| Oncology Medications That Will Be Covered Under Our Medical Benefit |
|---|
| Abraxane | Herceptin | Onivyde |
| Arzerra | Herceptin Hylecta | Ontruzant |
| Bavencio | Herzuma | Opdivo |
| Cyramza | Imfinzi | Poteligeo |
| Doxil/Lipodox | Kanjinti | Proleukin |
| Empliciti | Keytruda | Rituxan-Hycela |
| Fusilev | Khapzory | Tecentriq |
| Gazyva | Ogivri | Trazimera |
The Quality Care Cancer Program, which launches July 1, 2021, is administered by AIM Specialty Health®´´ (AIM), an independent company. You can learn more about this program, which helps ensure the cancer treatments we cover are safe and appropriate for our members, here.
This change only applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex®´ plans* with a three-tier pharmacy benefit. This change doesn’t apply to group Medicare Advantage and Federal Employee Program plans. If you’re a member of an affected plan and are currently filling these medications under the pharmacy benefit, you’ll be able to complete your treatment course without interruption.
If your plan includes medical benefits from Blue Cross and pharmacy benefits from another carrier, you can receive coverage for these medications from us under your medical benefit. To see if you’re also covered by your pharmacy benefits from another carrier, please refer to your pharmacy plan benefit materials.
Questions?
If you have any questions, call Team Blue at the Member Service number on your ID card.
*This doesn’t include Medex 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
Upcoming Coverage Changes for Certain Medications Moving from Our Medical to Pharmacy Benefit
Effective July 1, 2021, coverage for the following medications will move out of our medical benefit and only be included under our pharmacy benefit. This change will apply to all medical plans, except Managed Blue for Seniors, group Medicare Advantage, group Medex®´, and Federal Employee Program plans.
| Medications Moving from Our Medical to Pharmacy Benefit |
|---|
| Available at Retail Pharmacies | Durolane* | Gel-One* | GelSyn-3* |
| Monovisc* | Triluron* | Trivisc* |
| Must Be Filled at a Specialty Pharmacy | Bynfezia | Cosentyx* | Dupixent* |
| Fasenra* | Kevzara* | Nucala* |
| Siliq* | Strensiq | Tegsedi* |
| Tremfya* | | |
Members who have plans with the Blue Cross Blue Shield of Massachusetts formulary, as well as Medex®’ plans** with a three-tier pharmacy benefit, or the National Preferred Formulary*** will receive coverage for these medications under their pharmacy benefit upon the effective date. Members with these plans will not experience a break in coverage as these medications move from the medical benefit to the pharmacy benefit. Group Medex plans with a three-tier pharmacy benefit will include coverage for these medications under both the medical and pharmacy benefit. If you don’t have pharmacy coverage from Blue Cross Blue Shield of Massachusetts, refer to your pharmacy plan benefit materials for coverage details on these medications.
If affected, we’ll contact you about this change and help you transition your prescription to support uninterrupted coverage.
This change doesn’t apply when these medications are administered in inpatient, surgical day care, ambulatory surgery center, and emergency department settings.
Questions?
For more information, call Team Blue at the Member Service number on your ID card.
*These medications require prior authorization.
**This doesn’t include Medex 2 plans with Blue MedicareRx (PDP) prescription drug coverage.
***Plans with the National Preferred Formulary may have additional coverage requirements for these medications.
Quality Care Cancer Program Launching July 1, 2021
We’re launching our new Quality Care Cancer Program on July 1, 2021, to help ensure that our members receive cancer care that is appropriate and safe, based on clinical guidelines. Through the Quality Care Cancer Program, board-certified oncologists and oncology-trained nurses will be available to discuss covered treatment options with our members’ doctors.
Our Quality Care Cancer Program applies to all commercial and Medicare Advantage plan members seeking outpatient medical oncology treatment (chemotherapy, immunotherapy, and supportive medications), or outpatient radiation oncology treatment. Doctors who order these types of treatments for our members will request Prior Authorization through AIM Specialty Health®´ (AIM), an independent company that will administer this program.
When a member’s doctor submits a treatment plan for prior authorization that meets evidence-based clinical criteria for the cancer being treated, they will get real-time approval. If the requested treatment doesn’t meet evidence-based criteria, the member’s doctor can request a peer-to-peer consultation with an AIM oncologist to discuss the covered, evidence-based treatments that are best for the member.
For a member already receiving cancer treatment at the time of the Quality Care Cancer Program’s launch, their doctor will need to request a prior authorization for the continuation of coverage. If a member’s treatment plan changes, their doctor will then request a new prior authorization for health plan coverage.
Because scientific and medical advances are rapidly changing cancer treatment, and there are wide variations in the way doctors treat patients with the same type of cancer, cancer care quality programs like ours are becoming necessary.
The Quality Care Cancer Program is designed to help our members receive the most appropriate and effective treatment regimen, so they can have the best possible outcome with the least number of side effects. If you have any questions, please contact member service.
Make a Plan to Get Your Flu Shot
Flu season can last through the end of May. And with COVID-19 it’s more important than ever to get your flu shot. It will keep you, your family, and community from getting sick during this crucial time. You can get your flu shot at no additional cost* from in-network providers like pharmacies, limited service clinics, and your doctor if you have an upcoming appointment.
Follow these steps, so you can plan out the easiest and safest way to get vaccinated:
- Find a location near you using vaccinefinder.org.
- Verify the location is in your network by signing in to MyBlue and visiting Find a Doctor & Estimate Costs.
- Make an appointment ahead of time, if possible. If not, ask when there are slower times during the week.
Learn More
*CDC-recommended flu vaccines are covered in full when administered by an in-network provider. Exceptions may apply. Check your plan materials for details.
Added Behavioral Health Coverage for Children and Adolescents
Beginning January 1, 2021, upon plan renewal, Blue Cross Blue Shield of Massachusetts will cover the following behavioral health services for members under 19 years old:
- Family Support and Training (FS&T): medically necessary education for a child’s parent or caregiver, given in the home, to help resolve the child’s emotional or behavioral health needs and identify additional services and support in their community.
- Therapeutic Mentoring (TM): medically necessary services for a child, given in the home, to support the child’s social functioning, especially after an emotional or behavioral health disorder diagnosis. TM services may include supporting, coaching, and training the child in age-appropriate behaviors, interpersonal communication, problem-solving, conflict resolution, and relating appropriately to other children, adolescents, and adults.
These new services are in addition to the Intensive Community-Based Treatment (ICBT) behavioral health services we already cover for children and adolescents:
- In-Home Behavioral Services: Behavior Management Monitoring and Behavior Management Therapy
- In-Home Therapy: Therapeutic Clinical Intervention and Ongoing Therapeutic Training and Support
- Intensive Care Coordination
- Community-Based Acute Treatment for Children and Adolescents (CBAT)
- Intensive Community-Based Acute Treatment for Children and Adolescents (ICBAT)
- Mobile Crisis Intervention (MCI)
ICBT offers a family- and home-based treatment approach for children and adolescents; CBAT and ICBAT are forms of acute residential treatment. Wrap-around services are community-based interventions developed by a multidisciplinary team and personalized to focus on the strengths and needs of the child or adolescent and their family. ICBT services given outside Massachusetts may vary based on the state. Your Evidence of Coverage and other benefit documents will be updated when your plan is renewed.
If you have questions, call the Member Service number on your ID card.
Upcoming Prior Authorization Changes for Medications Covered Under the PPO and EPO Medical Benefit
Beginning January 1, 2021, we’re adding Prior Authorization requirements for members with PPO and EPO plans for certain medications covered under the medical benefit. In order for you to receive coverage for the medications included in the list, your doctor must first obtain Prior Authorization from us. If you’re currently using one of the listed medications, you’ll need an approved authorization to receive continued coverage.
To see the full list of medications that will require Prior Authorization, go to the Medication Lookup Tool and select Medical Benefit Prior Authorization Medication List under Important Information.
When coverage is requested for a medication that requires Prior Authorization, we review the request to determine whether the medication is medically necessary. We base the review on the patient’s diagnosis and medication history, as well as U.S. Food and Drug Administration and other evidence-based guidelines.
Prior Authorization is required for these medications when administered:
- In a clinician’s or physician’s office
- By a home health care provider
- By a home infusion therapy provider
- In an outpatient hospital or dialysis setting
This change doesn’t affect medications received in inpatient, surgical day care, urgent care, and emergency department settings. It also doesn’t apply to members of the following:
- Federal Employee Program
- Medex®´
- Managed Blue for Seniors
- Medicare*
- Indemnity
*Some Medicare plans have Prior Authorization requirements for medications. Please see your plan benefits for more details.
Benefits of Prior Authorization
- Ensures that covered medications are safe, effective, and medically necessary
- Avoids surprise out-of-pocket costs by confirming coverage before getting treatment
Questions?
If you have any questions, please call Member Service at the number on the front of your ID card.
