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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 our 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 Aciphex Sprinkle Dexilant esomeprazole magnesium esomeprazole strontium
First-Lansoprazole First-Omeprazole lansoprazole Nexium omeprazole
omeprazole sodium bicarbonate pantoprazole Prevacid Prilosec Protonix
rabeprazole Zegerid      

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, what members pay for the following medications may increase or decrease:

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)
These medications are moving to a higher tier, which means they may cost more for members.
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 less for members.
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 3e

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.

Medications with New Quality Care Dosing Limit
To make sure that the quantity and dose of a medication meets 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)
A member's 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 Ellipta

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 Eligard†† leuprolide acetate†† Lupron Depot††
Lupron Depot Pediatric†† Zoladex†† haldol decanoate haloperidol decanoate

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

How Members Can Save Money for Long-Term Prescriptions
Members may be able to save money for long-term medications, also known as maintenance medications, when they order prescriptions through our mail order pharmacy. Members can visit MyBlue to learn more, or get started online by visiting Express Scripts®'', an independent company that manages member pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts. Members can also call them directly at 1-800-892-5119.

Questions?
If you have any questions, please contact your Account Executive.

Blue Cross Blue Shield of Massachusetts

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