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Pharmacy Benefit Updates

Osteoarthritis injections: coverage change

Effective July 1, 2014, the following medications will not be covered for select plans with pharmacy benefits and for Medex® plans with pharmacy benefits. If you are impacted by this change, you will also get a letter with more details.

  • Orthovisc
  • Synvisc
  • Synvisc-One

How we came to this decision:

We reviewed new evidence-based guidelines on treatment of osteoarthritis of the knee, including guidance from the American Academy of Orthopaedic Surgeons and the Blue Cross Blue Shield Association’s Technology Evaluation Center.

New Changes at www.express-scripts.com

Express Scripts, has updated its website. Enhancements include new self-service capabilities, which help make prescription management faster and easier.

Go to www.express-scripts.com to take a look!

Express Scripts administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts.

Specialty Pharmacy Name Change

On January 1, 2014, CuraScript®, a subsidiary of Express Script®, will join Accredo Health Group, Inc.® You can use the Accredo website and telephone number listed below for questions related to a specialty medication. This change will not interrupt or delay future refills, as only the name of the pharmacy is changing.

Accredo Health Group, Inc.
1-877-988-0058
www.accredo.com

Changes to select medications when administered in a doctor's office or hospital1

Starting January 1, 2014, the following medications will no longer be covered through your medical benefit. They will only be covered if they are purchased prescription through your pharmacy benefits and administered by your physician. If you do not have pharmacy benefits, speak to your benefits manager to learn how to obtain prescription(s).

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

The following medications will no longer be covered when administered in a doctor's office or hospital setting. They will only be covered when purchased from a retail pharmacy in our specialty network. If you do not have pharmacy benefits, speak to your benefits manager to learn how to obtain prescription(s).

Drug Class Medication Name
Fertility Regulator Ovidrel2
Antipsoriatic Stelara
Anti-TNF-alpha - Monoclonoal Antibodies Simponi
Bone Density Regulators Prolia, XGEVA
 
GGnRH/LHRH Antagonists Cetrotide
Growth Hormone Somavert
Receptor Antagonist  
Interleukin-1 Blockers Arcalyst
Interleukin-1beta Blockers Ilaris
Multiple Sclerosis Agent Extavia
Antineoplastic or Premalignant Lesion Agent - Topical Panretin

Over-the-Counter Medications
For non-grandfathered health plans under the Affordable Care Act, the following list includes over-the-counter medications that are covered with no cost share when they are prescribed for you by your doctor. This list is up to date as of January 1, 2014, and is subject to change at any time.

  • Generic aspirin (81mg) is covered for females age 59-79 and males age 45-79.
  • Generic folic acid is covered for females up to age 50.
  • Generic iron is covered for infants up to 12 months old.
  • Generic smoking-cessation drugs are covered for up to a 90-day supply per calendar year.
  • Generic Vitamin D is covered for females and males age 65 and older.
  • Generic women's contraceptives (e.g., female condoms, sponges, and spermicide) are covered.

New "My Rx Choice" Program for Commercial Accounts with pharmacy benefits

Beginning January 1, 2014, Express Scripts will begin a promotional mailing campaign to encourage the use of mail service delivery. Members taking a medication that would be suitable for the mail service pharmacy will receive a letter to educate them on the benefits of and potential savings of the mail service pharmacy program. Please contact your Account Executive with any questions.

 

1These changes do not impact Medex®' plans with a three tier pharmacy benefit
2Purchase of this medication is only available when purchased through a network specialty fertility retail pharmacy.

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.

Changes to Your Pharmacy Benefits for 2014
Because you've chosen to be more involved in your health care, we want you to be aware of changes early so you can plan. In 2014, we will be updating our drug formulary to adjust how some medications are covered, and specify that certain specialty drugs be purchased at a network specialty pharmacy. As a Blue Cross member, you will continue to have access to a variety of effective medications at affordable prices. Changes will be made in:

  • Non-covered medication status (Some specialty drugs must now be purchased at a network specialty pharmacy, and will not be covered if administered in a doctor's office or outpatient facility.)
  • Medication tier status
  • Quality Care Dosing limits
  • Other pharmacy medical policies, including prior authorizations required

To get the complete details for these changes as of October 15, 2013, go to Member Central.

Pharmacy Changes Effective January 1, 2013

Coming January 1, 2013: 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, 2012.

Medications Changing to Non-Covered Status-Effective January 1, 2013
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
HMG Cholesterol Inhibitors Lipitor tablets (members currently using this medication will not be required to obtain a formulary exception for coverage)
Phosphate Binders Phoslyra solution
Low Molecular Weight Heparins Arixtra, Fragmin, Innohep, and Lovenox injections
Glaucoma Cosopt PF ophthalmic solution
Ophthalmic Antibiotic Combinations Tobradex ST solution

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

Medications Changing Tier Status-Effective January 1, 2013
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 status. Depending on the indicated tier change, members may be required to pay more or less for these medications.

The medications below will be changing to the following tier levels:

Drug Class Medication Name Covered Tier Level as of January 1, 2013
Diabetic Testing Strips Blood Glucose Test Strips
Control Test Strips
Easy Check Glucose Test Strips
Glucolab Test Strips
Infinity Test Strips
Keynote Test Strips
Microdot Test Strips
Solo V2 Test Strips
Ultratrack Test Strips
Tier 3

For members with the BlueValue Rx formulary, these supplies will be non-covered
Pegylated Interferons Peg-Intron Tier 3

The medication Rozerem (sedative hypnotic) will become a Tier 3 covered medication and members will no longer require a formulary exception for coverage to be provided.

New Quality Care Dosing (QCD) Limits-Effective January 1, 2013
To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration (FDA), manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medications listed:

Medication Dosage QCD limit
Lidoderm (lidocaine) patch 5% 90 patches per prescription

Prior Authorization for Medications Administered Using the Medical Benefit-Effective January 1, 2013
For members enrolled in our HMO, POS, and Access Blue plans, prior authorization is required under members' medical benefits for certain medications that are administered in a doctor's office, hospital outpatient setting, or by a home infusion therapy provider. This requirement will also apply to the following medications.

  • Alphanine®' SD
  • Bebulin VH
  • Benefix®'
  • Corifact®'
  • Eylea®'
  • Gammaked®'
  • Gamunex®'-c
  • Lucentis®''
  • Macugen®'
  • Omnontys®'
  • Pegasys®' proclick
  • Regranex®'
  • Wilate®'
  • Xiaflex®'

The prior authorization requirements may already apply when members fill their prescriptions at retail pharmacies.

Benefit Exclusions-Effective January 1, 2013
All drugs in the therapeutic class of ophthalmic solutions used to treat allergies will be excluded from our pharmacy benefit coverage. Formulary exceptions, including those previously approved, will no longer be available for this class of medications. This change will apply to all commercial plans, group Medex® plans with pharmacy benefits, and Managed Blue for Seniors.

Drugs currently in this class include: Alamast, Alocril, Alomide, Azelastine HCL, Bepreve, Cromlyn Sodium, Elestat, Emadine, Epinastine HCL, Lastacaft, Pataday, Patanol.

In addition, for group Medex plans with pharmacy and Managed Blue for Seniors, all drugs in the therapeutic class of non-sedating antihistamines will be excluded from our pharmacy benefit coverage effective January 1, 2013. This exclusion already exists within our commercial plans. Medications in this class include Allegra D, and Clarinex.

We are making these changes due to the over-the-counter availability of several products in these classes, which can be purchased without a prescription.