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General Plan Updates

Safely Dispose of Expired or Unwanted Drugs on April 26

Medications don't last forever. Over time, their chemical properties change, making them less effective—even dangerous.

The U.S. Drug Enforcement Administration's next National Prescription Drug Take Back Day is on Saturday, April 26, 2014, from 10:00 a.m. to 2:00 p.m.

Now is a great time to go through your medicine cabinet and check the expiration dates on your medications—everything from aspirin to prescription drugs. Take all those expired medications and bring them to your local disposal location.

To find Take Back locations in your area, please use the U.S. Drug Enforcement Administration’s search tool.

Chiropractic Services Change for Local Managed Care Plans

For small groups and individuals, the following change is effective January 1, 2014, for local HMO Blue® and Access BlueSM plans only: Upon plan renewal, there will no longer be an age restriction on chiropractic services. These plans will continue to have a 12-visit annual coverage maximum for chiropractic services.

To find out more visit Member Central's Direct Pay Changes section, for more information.

Coming January 1, 2014: Updates to Pharmacy Formulary Program
With these changes, members and doctors will continue accessing a variety of safe, clinically effective medications at affordable prices.

Which Plans Will Be Affected?

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

Doctors and hospitals have already been advised of these changes. Members affected by any of these changes will be notified directly no later than December 1, 2013.

Medications Changing to Non-Covered Status
After careful consideration and cost evaluation of each drug's covered alternatives, the following medications will no longer be covered.

Drug Class Non Covered Medication or Supply
Insulins Novolog, Novolin
Migraine Treatments Alsuma, Relpax, Zomig/ZMT (members currently using these medications will not be required to obtain a formulary exception for coverage)
H. Pylori Treatments Pylera, Helidac, PrevPac
Topical Steroids Clobex
Hyaluronic Acids/Joint Fluid Replacement Euflexxa, Hyalgan, Supartz
Glucose Testing Supplies-Testing Strips Precision X-tra (members currently using this medication will not be required to obtain a formulary exception for coverage and will be covered at Tier 3)

When medically necessary, a health care provider may request an exception to have these medications covered.

Medications Changing Tier Status
When we determine that a medication's clinical and financial value changes relative to alternative medications in its class, we change the medication's tier. Depending on the tier change, members may be required to pay more or less for these medications.

The medications below will change to the following tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2014
Irritable Bowel Treatments Amitiza Tier 2
Hormone Replacement Therapy Premarin Tier 2
Women's contraceptives Nuvaring, Ortho-Evra, Depo-Provera-150, Medroxyprogesterone Tier 1

New Quality Care Dosing Limits
To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration, manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medication below:

Medication Name Dosage QCD limit
Epinephrine, Epi-pen, Auvi-Q All Strengths 2 injections per prescription

Medications requiring Prior Authorization Effective January 1, 2014
The following medications will require a prior authorization

Drug Class Medication Name
Compounded Medications ketamine, gabapentin, diclofenac, ketoprofen, flurbiprofen, oral erectile dysfunction medications and oral pain/analgesic medications when included as part of a compounded medication
Weight Loss Belviq

New Step Therapy Policy-Effective January 1,2014

Drug Class Medication Name
Oral Medications for treatment of Prostate Cancer Step 1: Zytiga
Step 2: Xtandi (members currently using this medication will not be required to obtain a prior authorization for coverage)

Medications no longer covered when administered in a doctor's office or hospital setting* 
The following medications will no longer be covered when administered in a doctor's office or hospital setting. They will only be covered if they are purchased through your pharmacy benefits.

Drug Class Medication Name
Hyaluronic Acids/Joint Fluid Replacement Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-one

Coverage will no longer be available for the following medications when administered in a doctor's office or hospital setting. Coverage will only be available when purchased from a retail pharmacy in our specialty network.

Drug Class Medication Name
Fertility Regulator Ovidrel 
Antipsoriatic Stelara
Anti-TNF-alpha - Monoclonoal Antibodies Simponi
Bone Density Regulators Prolia, Xgeva
GnRH/LHRH Antagonists Cetrotide
Growth Hormone Receptor Antagonist Somavert
Interleukin-1 Blockers Arcalyst
Interleukin-1beta Blockers Ilaris
Multiple Sclerosis Agent Extavia
Antineoplastic or Premalignant Lesion Agent Topical Panretin

*These changes do not impact Medex plans with a three tier pharmacy benefit
Purchase of this medication is only available when purchased through a network specialty fertility retail pharmacy.

MA State Law requires coverage for oral anticancer drugs

On January 1, 2013, Massachusetts Governor Deval Patrick signed a law that requires a health insurance plan to cover prescribed, orally administered anticancer medications the used to kill or slow the growth of cancerous cells on a basis no less favorable than intravenously administered or injected cancer medications covered as medical benefits.

This means, for most plans, Blue Cross Blue Shield of Massachusetts will provide full coverage for orally administered anticancer drugs. For HSA-compliant high deductible health plans, the overall deductible will still be applicable.

Eligible members that purchased an oral anticancer medication will be reimbursed for any cost share (deductible, copayment, or co-insurance) paid on or after their plans 2013 renewal date. This reimbursement will occur prior to the first of September.

For HSA-compliant high deductible health plans, the overall deductible will still be applicable.

Thanks to recent changes in Massachusetts law, Blue Cross Blue Shield of Massachusetts is now providing new or additional coverage in three areas of services. They are:

Hearing Aids for Children1

Children (age 21 or younger) are covered for the cost of one hearing aid per hearing impaired ear, up to $2,000 for each hearing aid every 36 months. This coverage also includes services related to a covered hearing aid device that are prescribed by a licensed audiologist, hearing instrument specialist, or an ear, nose, and throat (ENT) provider, including:

  • The initial hearing aid evaluation
  • Fitting and adjustments
  • Qualifying supplies such as ear molds.

The member may choose a higher-priced hearing aid but will be responsible for expenses above the $2,000 per ear coverage limit. Coverage is subject to all of the requirements of the health plan and does not include replacement hearing aid batteries.

This change will become effective once your plan renews in 2013.

Cleft Lip and Cleft Palate Treatment for Children1

Children under the age of 18 can receive coverage for treatment of a cleft lip and cleft palate, including:

  • Medical, dental, oral, and facial surgery
  • Surgical management and follow-up care by oral and plastic surgeons
  • Orthodontic treatment and management
  • Preventive and restorative dentistry
  • Speech therapy
  • Audiology and nutrition services

We currently provide coverage for most of these services and have updated our plans to include the necessary dental and orthodontic services, subject to the requirements of the health plan. Please refer to your evidence of coverage for details.

This change will become effective once your plan renews in 2013.

Services Provided by Physician Assistants

With the new law, your care will be covered if you choose to see a participating physician assistant for health maintenance, diagnosis, and treatment. Whats more, physician assistants will be included on the list of participating providers, and members will have the opportunity to select a physician assistant as a primary care provider.

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

1. Excluding Managed Blue for SeniorsSM, Medicare Advantage, and Medex.®

Changes to Women's Preventive Health Services Coverage
The U.S. Department of Health and Human Services has issued guidelines to ensure that all women have access to preventive health services necessary for women's health and wellbeing. These new guidelines require health plans and health insurance issuers to cover the recommended women's preventive health services without charging a copayment, co-insurance, or deductible for in-network services.

Read the entire update and learn about other national healthcare reform updates.

New Mothers: Breast Pumps May Be Covered Without Cost Share
Effective August 1, 2012, your benefits may include coverage for the rental or purchase of a dual electric breast pump or a manual breast pump and breastfeeding support without cost share. This means these services may be available to you without a copayment, co-insurance, or deductible. Coverage for these services can be found under your durable medical equipment (DME) benefit and are available only from Blue Cross Blue Shield of Massachusetts-contracted DME providers with a prescription. This benefit is subject to your health plan's overall benefits and network requirements.

Note: This change will apply to you on your health plan renewal date.

To see when your health plan renews, or to check your benefits, log in to Member Central and click on Review My Benefits.

Here's how to find participating durable medical equipment companies who can supply you with a breast pump:

  • Visit Find a Doctor and click on Find Other Medical Services/Supplies.
  • At the top of the page, select Detailed Search by Network and Location.
  • Select your health plan.
  • Select DME-Breast Pumps on the Select a Specialty menu.
  • Enter your location information at the bottom of the page.
  • Click the Search Now button.

To find information about breastfeeding, please visit Living Healthy Babies.

If you have any questions about your benefits, please call the number on the front of your ID card.

2012 Product Portfolio and Benefit Design Updates
At Blue Cross Blue Shield of Massachusetts, our highest priority is to make quality health care affordable. Part of our ongoing commitment to employers and their employees is to offer high-quality, affordable health care product solutions. We also believe that by providing consistency across our product portfolio and simplifying the administration, it will lead to more affordable care and a clearer understanding of our products. As a result, we are implementing a number of enhancements to our standard plan designs as well as introducing new plan designs. Please review the Standard Plan Design Benefit Changes that apply to new and existing plans beginning January 1, 2012.

Blue Options and Hospital Choice Cost Sharing Network Changes for 2012
We are pleased to let you know that in a one-day change for all new sales and existing customers. As of January 1, 2012, four Massachusetts hospitals will be shifting to more favorable tiers within the Blue Options plans. This change will also impact the member cost sharing level of two hospitals in the Hospital Choice Cost Sharing plan feature.

In all cases, the changes are positive for members, as they will pay less for care at these hospitals.

The hospitals are changing for one of two reasons:

  • The hospitals significantly improved their cost performance
  • The hospitals are now able to be measured for quality and met our quality benchmark

Blue Options Changes

Hospital Name New Blue Options Tier Reason for Change Previous Blue Options Tier
Cooley Dickinson Hospital Standard Benefits Tier
(mid-level cost sharing)
Cost Score Basic Benefits Tier
(highest cost sharing)
Massachusetts Eye and Ear Infirmary Enhanced Benefits Tier
(lowest cost sharing)
Quality Score
(first time hospital was measured)
Standard Benefits Tier
(mid-level cost sharing)
New England Baptist Hospital Enhanced Benefits Tier
(lowest cost sharing)
Quality Score
(first time hospital was measured)
Standard Benefits Tier
(mid-level cost sharing)
St. Anne's Hospital Standard Benefits Tier
(mid-level cost sharing)
Cost Score Basic Benefits Tier
(highest cost sharing)

Hospital Choice Cost Sharing (HCCS) Changes

Hospital Name New HCCS Cost Sharing Level Previous HCCS Cost Sharing Level
Cooley Dickinson Hospital Lower Cost Sharing Higher Cost Sharing
St. Anne's Hospital Lower Cost Sharing Higher Cost Sharing

Note: There are no cost sharing level changes for the Hospital Choice Cost Sharing feature for Massachusetts Eye and Ear Infirmary and New England Baptist Hospital, as they are already listed as Lower Cost Share.


2012 Hospital Lists

2011 Product Portfolio and Benefit Design Updates
As part of our ongoing efforts to enhance our product portfolio and address the immediate implications of national health care reform and Federal Mental Health Parity, effective January 1, 2011, we made several changes to our standard plan designs. Please review the PDF Product Portfolio and Benefit Design Updates brochure for a detailed overview of the changes.

Mandated Autism Spectrum Disorder Benefits, Effective January 1, 2011
Massachusetts enacted a new law requiring health insurers to provide coverage for the diagnosis and treatment of autism spectrum disorders. In accordance with the new law, new plans issued or delivered on or after January 1, 2011 will include these new autism benefits. For existing plans, benefits will be added on the plan's renewal/anniversary date on or after January 1, 2011.1

Covered Benefits
Benefits for the medically necessary diagnosis and treatment of autism spectrum disorders, including Pervasive Developmental Disorder, Asperger's Disorder, and Pervasive Developmental Disorders Not Otherwise Specified, will be provided when services are furnished by a covered provider, as described in your subscriber certificate or benefit description or by board certified behavior analysts supervising or performing applied behavior analysis (ABA), as noted below, who are not otherwise defined as a covered provider in your subscriber certificate or benefit description. Benefits will be subject to the same terms and conditions as benefits for other conditions.

For the diagnosis of autism spectrum disorders, we will cover medically necessary assessments, evaluations, and testing. For individuals diagnosed with an autism spectrum disorder, our policies will cover the following medically necessary treatment services when provided or ordered by a licensed physician or psychologist:

  • Habilitative or rehabilitative care, including applied behavior analysis (ABA) when under the supervision of a board certified behavior analyst. ABA services will be considered intermediate level of care under a member's behavioral health benefits. ABA services will require prior authorization.
  • Pharmacy care (contingent upon plan inclusion of pharmacy coverage)
  • Psychiatric care
  • Psychological care
  • Therapeutic care

Benefits for the treatment and diagnosis of autism spectrum disorders will also meet the following requirements:

  • Annual or lifetime dollar limitations will be comparable to those applied for the diagnosis and treatment of physical disorders.
  • There will be no limits on the number of visits an individual can make to an autism services provider.
  • Benefits already available under a plan will not be limited due to the addition of these new benefits.

These benefits shall not affect an obligation to provide services to an individual under an individualized family service plan, an individualized education program or an individualized service plan. Services related to autism spectrum disorder provided by school personnel under an individualized education program are not subject to reimbursement under these benefits.

For More Information
To learn more about these requirements or to see the benefits specific to your plan, create an account and log in to Member Central or call the Member Service number on the front of your ID card.

1. Self-funded group benefit plans are not required to accept the provisions required by this new state law. Please see your benefit materials or your employer for information about your benefits for autism spectrum disorder.

Payment Changes for Out-of-Network Providers
Blue Cross Blue Shield of Massachusetts is changing the way we pay doctors and other providers who are not in your plan's network.

Payments for covered services received from an out-of-network provider may be mailed directly to you in accordance with your plan and our policies. The checks we mail you will be for covered services, less any copayment, co-insurance, or deductible; and, it will be your responsibility to provide the payments to the out-of-network providers. The out-of-network providers should bill you directly for the services they perform.

In many cases, out-of-network providers charge as much as three to five times more than in-network providers.1 This can contribute to the rising cost of health care, and ultimately, to the cost of your premiums.

For help in finding a participating provider, please use our Find a Doctor tool or call Member Service at the number on the front of your ID card.

1. This average does not include payment for Medicare Advantage members.