REMINDER - Effective July 1, 2025, medical policy change for the Blue Cross Blue Shield of Massachusetts formulary

Effective July 1, 2025, we're updating the following medical policy. This change affects our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans¹ with a three-tier pharmacy benefit.

Questions?

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

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

UPDATE - Effective July 1, 2025, changes to the Blue Cross Blue Shield of Massachusetts formulary and medical policy updates

Effective July 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans* with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective July 1, 2025.

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

Medications no longer covered starting July 1, 2025

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

**Members currently taking this medication will be allowed coverage so they can continue using them. They’ll pay the highest copay amount at checkout.

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, the medications listed below now require Quality Care Dosing.

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.

a. This medication was previously non-covered.
b. This medication was previously covered at Tier 2.
c. This medication was previously covered at Tier 3.
d. This medication was previously covered at Tier 4.
e. This medication was previously covered at Tier 5.
f. This medication was previously covered at Tier 6.

Medical policy updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, 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 that your prescribing doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for more information?

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

Questions?

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

REMINDER - Effective July 1, 2025, medical policy change for the Blue Cross Blue Shield of Massachusetts formulary

Effective July 1, 2025, we're updating the following medical policy. This change affects our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans¹ with a three-tier pharmacy benefit.

Questions?

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

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

PAY SET OUT-OF-POCKET COSTS FOR SELECT MEDICATIONS

Effective on your plan renewal beginning July 1, 2025, members on select plans will pay specific out-of-pocket costs set by the Commonwealth of Massachusetts for select medications that treat the following conditions:

• asthma
• diabetes (select insulins)
• select heart conditions, including congestive heart failure and coronary artery disease

This change is required by a new Massachusetts law and applies to select plans with the Blue Cross Blue Shield of Massachusetts formulary, and the Standard Control with Advanced Control Specialty Formulary.

To find out the cost of your medication, sign in to MyBlue and select Price a Medication under My Medications.

Effective July 1, 2025, changes to the Blue Cross Blue Shield of Massachusetts formulary and medical policy updates

Effective July 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans* with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective July 1, 2025.

Complete details about these changes will be available by May 27, 2025. 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.}

UPDATE - Effective July 1, 2025, medical policy change for the Blue Cross Blue Shield of Massachusetts formulary

Effective July 1, 2025, we're updating the following medical policy. This change affects our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´ plans¹ with a three-tier pharmacy benefit.

Questions?

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

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

Effective July 1, 2025, medical policy change for the Blue Cross Blue Shield of Massachusetts formulary

Effective July 1, 2025, we're updating a medical policy for our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´1 plans with a three-tier pharmacy benefit.

Complete details about these changes will be available by February 28, 2025. Check back at that time.

Questions?

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

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

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

Effective January 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´1 plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective January 1, 2025.

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

Medications no longer covered starting January 1, 2025

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

^{1. We’ll continue to cover this medication if you’re already taking it. However, you’ll pay your plan’s highest-tier cost.}

Medications excluded from coverage

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

Medications with new quality care dosing (QCD) limits

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, the QCD limit for the below medications has changed.

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.  

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

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

Medications requiring prior authorization

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

^{3. If you’re currently filling prescriptions for this medication, you won’t need prior authorization.}

Medical policy updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, 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 that your prescribing doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for more information?

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

Questions?

If you have any questions, contact your account executive.

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

Effective January 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective January 1, 2025.

Complete details about these changes will be available by October 31, 2024 at bluecrossma.org/pharmacy_updates under the Blue Cross Formulary tab.

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.

Changes to Our Specialty Pharmacy Network for Fertility Medications

On December 1, 2024, Encompass Fertility^®´, a subsidiary of CVS Pharmacy that administers specialty fertility medications, will be leaving our specialty pharmacy network. At this time, CVS Specialty^TM will be joining our specialty pharmacy network to administer specialty fertility medications for our members.

If you currently fill your medication through Encompass Fertility, CVS Specialty will contact you by December 1, 2024 to help you transition to CVS Specialty.

This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the Standard Control with Advanced Control Specialty Formulary. For more information, visit our specialty medications resource page.

Questions?

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

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

Effective January 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´1 plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective January 1, 2025.

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

Medications no longer covered starting January 1, 2025

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

^{1. We’ll continue to cover this medication if you’re already taking it. However, you’ll pay your plan’s highest-tier cost.}

Medications excluded from coverage

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

Medications with new quality care dosing (QCD) limits

To make sure that the quantity and dose of a medication meet the Food and Drug Administration, manufacturer, and clinical recommendations, the QCD limit for the below medications has changed.

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.  

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

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

Medications requiring prior authorization

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

^{3. If you’re currently filling prescriptions for this medication, you won’t need prior authorization.}

Medical policy updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, 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 that your prescribing doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for more information?

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

Questions?

If you have any questions, contact your account executive.

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

Effective January 1, 2025, we’re updating our formulary (list of covered medications) for medical plans with pharmacy benefits, as well as Medex^®´* plans with a three-tier pharmacy benefit. As part of this update, certain medications may:

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

We’re also making medical policy changes, effective January 1, 2025.

Complete details about these changes will be available by October 31, 2024 at bluecrossma.org/pharmacy_updates under the Blue Cross Formulary tab.

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 May 15, 2024, Select Diabetes and Weight-Loss Medications No Longer Available Through the Mail Service Pharmacy

Effective May 15, 2024, due to a medication shortage, you won’t be able to fill the following diabetes and weight-loss medications in 90-day supplies through the mail service pharmacy:

These medications will continue to be available in 30-day supplies through in-network retail pharmacies. If you fill these medications through the mail service pharmacy, you should have received a letter from CVS Customer Care with more information about the change.

If you want to find an in-network pharmacy that’s convenient to you, sign in to MyBlue, then select Find a Pharmacy under My Medications. You can also call Team Blue Member Service at the number on your ID card.

Questions?

If you have any questions, call CVS Customer Care at 1-877-817-0477 (TTY: 711).

On August 1, 2024, AllianceRx Walgreens Specialty Pharmacy will become Walgreens Specialty Pharmacy

AllianceRx Walgreens Specialty Pharmacy delivers specialty pharmacy services to individuals with complex medical conditions. On August 1, 2024, they’re changing their name to Walgreens Specialty Pharmacy. You don’t need to take any action if you’re currently using this pharmacy. They’ll continue to fill your covered prescriptions — just under a new name.

To reach Walgreens Specialty Pharmacy:

• Phone: 1-888-347-3416
• Fax: 1-877-231-8302

Questions?

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

Acaria Health Is Leaving Our Specialty Pharmacy Network

On July 1, 2024, Acaria Health will be leaving our specialty pharmacy network.

If you fill your prescriptions through Acaria Health, you can complete your current course of treatment with Acaria Health, but treatments starting on or after July 1, 2024 will need to be filled through through Accredo, AllianceRx Walgreens Pharmacy, or CVS Specialty in order to be covered. If you’re currently using Acaria Health, you should have received a letter from us about next steps.

This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary, and the Standard Control with Advanced Control Specialty Formulary. For more information about specialty medications, use our Medication Lookup tool.

Questions?

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

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

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

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

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

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

Medications No Longer Covered Starting July 1, 2024

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

*If you’re currently taking any of these medications, you’ll be allowed coverage so you can continue using them. You’ll pay the highest copay amount at checkout.

Medications Switching Tiers

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

a. This medication was previously non-covered.
b. This medication was previously covered at Tier 2.
c. This medication was previously covered at Tier 3.
d. This medication was previously covered at Tier 4.
e. This medication was previously covered at Tier 5.
f. This medication was previously covered at Tier 6.

Medical Policy Updates

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

• Step therapy policy changes that apply when the medication within the pharmacy medical policy is newly prescribed for members. With step therapy, 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 that your doctor has determined that a medication is necessary to treat you, based on specific medical standards.

Looking for More Information?

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

Questions?

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

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

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

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

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

Complete details about these changes will be available by May 31, 2024. Check back at that time.

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.}

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

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

Questions?

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

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

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

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

Complete details about these changes will be available by January 11, 2024. Check back at that time.

Questions?

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

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

Some Previously Announced Medical Policy Changes for the Blue Cross Blue Shield of Massachusetts Formulary Are Being Delayed

The medical policy changes below, which were previously announced to be effective January 1, 2024, are being delayed to March 1, 2024.

Questions?

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

AllianceRx Walgreens Pharmacy Will Join Our Specialty Pharmacy Network

On January 1, 2024, AllianceRx Walgreens Pharmacy will join our specialty pharmacy network. Specialty pharmacies provide medications that are used to treat certain complex health conditions. For more information about specialty medications, use our Medication Lookup tool.

This change applies to plans with the Blue Cross Blue Shield of Massachusetts Formulary, and the Standard Control with Advanced Control Specialty Formulary.

Questions?

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

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.

^{*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.

Medications Required to Be Filled at an In-Network Specialty Pharmacy

Effective January 1, 2024, the following medications will only be covered when filled at an in-network specialty pharmacy:

Prior Authorization Now Required for Briumvi and Ocrevus

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

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

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

Coverage Changes for Certain Medications Being Removed from Our Medical Benefit

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

• Simponi Aria
• Stelara

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.

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.}