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General Plan Updates

Important Changes to Covered Medications
Effective July 1, 2015, coverage will no longer be available for the medications listed in the table below when they are purchased by the doctor's office or outpatient hospital. In order to have these medications covered by your health plan, you will need to purchase them from a pharmacy in our retail specialty pharmacy network. If you carve out your pharmacy benefits to another pharmacy benefits manager, we encourage you to discuss this change with them and how the medications will be covered.

You should always talk to your doctor about available alternatives for getting your medication. Here are some options:

  • Get the medication from a retail pharmacy within our specialty network. A medication copay, deductible and/or coinsurance would apply, and the doctor will need to request prior authorization.
    • The medication can be shipped to the doctor's office or outpatient hospital clinic for administration. In these instances, an office visit copay, deductible, and/or coinsurance applies.
  • Get the medication through a home infusion therapy provider. The doctor can refer you to a network home infusion therapy provider who can provide the medication and administer it in the home or other convenient setting according to your home health care benefits.


If you currently receive medication from a home infusion therapy provider or dialysis facility, there is no change in your coverage. We will be notifying impacted members by June 1, 2015.

Medication Name Medication Class
IVIG Immune Serum
Remicade TNF Inhibitor
Botulinumtoxin Neuromuscular Blocker

Questions?
If you have any questions please contact us at the number on your Blue Cross ID.

Affordable Care Act Preventive Services Update
The United States Preventive Services Task Force (USPSTF) recently announced changes scheduled to go into effect in 2015. These updates will impact fully insured and self-insured non-grandfathered accounts, as well as grandfathered accounts that adopted Affordable Care Act preventive services benefits.

How are we implementing these changes?
To make the necessary changes and comply with these requirements, we are changing affected health plans to provide in-network coverage, without copayments, co-insurance, or deductibles for the affected preventive services. Coverage for these recommended services is subject to the individual health plan's network requirements and provisions.

Because the effective dates vary, we have streamlined the implementation approach to gain administrative efficiencies.

The table below provides a description of the services being affected and the effective dates.

Service USPSTF-Mandated Effective Date Blue Cross Implementation Approach
Dental carries prevention
  • Application of fluoride varnish to the primary teeth of all infants and children, by primary care clinicians in primary care practices
  • Applies to children starting at the age of primary tooth eruption through age 5
  • No limit on the number of applications per year

This does not apply to services by a dental health care provider.

Plan years beginning on or after 5/31/15 Effective 1/1/15 as a one-day change
Low-dose aspirin for pregnant women
  • Over-the-counter low-dose aspirin (81 mg/d) for pregnant women who are at high risk for preeclampsia
  • Must have a prescription from a licensed clinician
Plan years beginning on or after 9/30/15 Will be applied effective 10/1/15 as a one-day change

Have questions?
If you have any questions, please contact Member Service using the number printed on your Blue Cross ID card.

We're Updating Our Plans for 2015

Beginning January 1, 2015, we will be enhancing our product portfolio. Changes include updating our health plans in order to stay current with the Affordable Care Act and new state requirements.

To see how these changes will affect you, please review our Product Portfolio and Benefit Design Updates brochure by clicking the link below:

Bulletin Prohibits Health Plan Discrimination Toward Gender Identity or Gender Dysphoria

On June 20, 2014 the Massachusetts Division of Insurance (DOI) issued a bulletin to insurers related to a law that went into effect July 1, 2012 that protects "gender identity" or "gender dysphoria" against discrimination.

In its bulletin, the DOI notes that discrimination on the basis of gender identity or gender dysphoria is prohibited. The DOI also acknowledged that the law did not specifically amend health insurance laws; however, the Division has concluded that insurers may not exclude transgender benefits such as medically necessary gender reassignment surgery.

How is Blue Cross Addressing This?
Our health plans already cover many services related to gender identity or gender dysphoria, including behavioral health services with a focus on gender identity and related issues, as well as hormone therapy. In addition, we are in the process of amending all of our insured health plans to remove the current benefit exclusion for a service or supply that is related to gender reassignment surgery.

This change will be effective immediately for all fully insured commercial plans, including Medex and Medicare Advantage. If you have questions about your covered benefits, please call the number on the front of your ID card.

Open Enrollment: November 15, 2014 through February 15, 2015

As a member of Blue Cross Blue Shield of Massachusetts, you are already enrolled in a health plan that meets all state and federal coverage requirements and gives you access to doctors and hospitals across the state. Use the chart below to see if you need to take any action in the upcoming Open Enrollment period.

If you purchased coverage directly from Blue Cross Blue Shield of Massachusetts and you want to: Then:
Continue your current coverage Simply continue to pay your bill, and your policy will automatically renew.

Your current coverage ends on December 31. To keep your current coverage, you do not need to do anything during Open Enrollment.
Change your plan during Open Enrollment Starting November 15, you can log in or create a Member Central account and click on Renew Your Plan Now. The "Renew Your Plan Now" link will direct you to the online shopping site where you can select a new plan to begin on January 1.
If you purchased coverage through the Health Connector and you want to: Then:
Continue your current plan or change your coverage Your current coverage will be cancelled as of December 31. You must purchase a new Blue Cross Blue Shield policy, no later than December 23, through the Health Connector to avoid a gap in your coverage.

We encourage you to enroll and submit your payment as early as possible. You can choose your new plan as early as November 15 at www.mahealthconnector.org or you can call the Health Connector toll-free at 1-877-623-6765 or TTY: 1-877-623-7773.

To find out if you are eligible for a premium subsidy (financial help for your health plan's premium), please contact the Massachusetts Health Connector at 1-877-MA-ENROLL (623-6765) or visit their website. Premium subsidies are only available through the Health Connector and only the Health Connector can assist you in determining your eligibility.

Click here for more information.

 

Safely Dispose of Expired or Unwanted Drugs on September 27

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, September 27, 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.

New Moms: Get Your Breast Pump—at No Cost
Your coverage may include the rental or purchase of a dual electric breast pump or a manual breast pump at no cost to you. This means you do not have to pay a copayment, co-insurance, or a deductible. If you're eligible, you'll also be fully covered for breastfeeding support. Covered services are only available from Blue Cross contracted providers with a prescription. See how you can get your breast pump at no cost.

More Coverage for Preventive Services

As mandated by the Affordable Care Act, we're making changes to our preventive services coverage based on new recommendations from the United States Preventive Services Task Force. Effective September 24, 2014, and January 1, 2015, you will be covered for the services listed below without copayments, co-insurance, or deductibles.

Topic Effective date
Breast cancer preventive medications for women with increased risk Effective on or after 9/24/2014 upon renewal
BRCA risk assessment and genetic testing for women Effective on or after 1/1/15 upon renewal
Lung cancer screenings for adults age 55 to 80 with a 30-pack per year smoking history and who currently smoke or quit within the past 15 years Effective on or after 1/1/15 upon renewal

Final Regulations for Mental Health Parity and Addiction Equity Act

Final regulations regarding the Mental Health Parity and Addiction Equity Act (MHPAEA) are effective July 1, 2014 upon renewal and apply to all commercial plans, administrative service contracts, and fully insured plans—including grandfathered and non-grandfathered plans.

We are making the appropriate adjustments to our health plans as required to comply with the final regulations for accounts renewing on or after July 1, 2014. The final regulations build on the interim final regulations, which have been in place since February 2010, and do not require major changes to our health plans at this time.

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.

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.

Resources

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.