Blue Cross Blue Shield of Massachusetts is an Independent
Licensee of the Blue Cross and Blue Shield AssociationTable of
ContentsAbout This Guide and Online Resources1Mail Service
Pharmacy2Your Pharmacy Cost Share and ID Card2Top Covered
Medications Over-the-Counter Medications Quality Care Dosing Prior
Authorization Specialty Pharmacy Medications Step Therapy
Non-Covered Medications Medication Resource List Index New
Medication Approval Process Your Pharmacy ProgramEffective January
1, 2015
OverviewPharmacy Program OverviewOur pharmacy program is
designed to provide you andyour doctor with access to a wide
variety of safe, clinically effective medications. We have
carefully developed asubstantial formulary that includes many
medications ataffordable cost share levels. About This GuideThis
guide is up-to-date as of January 1, 2015, and is subject to
change. Keep this guide handy, and use it as a reference whenever
you need coverage information about a specic medication. To get the
most current coverage information about a specic medication, visit
our website atwww.bluecrossma.com/pharmacy. Top Covered
Medicationsincludes many commonlyprescribed covered medications and
your cost share tierthat applies Over-the-Counter
Medicationsincludes a list ofover-the-counter medications that are
covered whenprescribed for you by your doctor Quality Care
Dosingincludes a list of medicationssubject to Quality Care Dosing
limits Prior Authorizationincludes a list of medicationsthat
require Prior Authorization Specialty Pharmacy Medicationsincludes
a list ofmedications that are available through pharmacies in
theSpecialty Pharmacy Network Step Therapyincludes a list of
medications subject toStep Therapy Medication Resource List
Indexincludes all prescriptionmedications listed in this booklet,
along with the page(s)on which they can be foundOnline
ResourcesFrom our main website, www.bluecrossma.com, to the
www.express-scripts.com website, we offer a varietyof online
resources to help you manage your medications. Search for
Medication Information. To learn whetheryour medications will be
covered, you can visitwww.bluecrossma.com/pharmacy, and use
theMedication Look Up feature, listed on the left-hand sideof the
page. You can use this tool before you enroll. (Themedication
information represents our standard pharmacycoverage; your
individual coverage may vary.) Our 2015formulary changes will not
be reected in this tool untilJanuary 1, 2015. Member Central. Want
more detailed information aboutyour health care coverage, claims,
or deductibles? You canlog on to Member Central by going to our
website,www.bluecrossma.com/member-central. To register, click
Create an Account, on the upper right-hand sideof the page.If youre
already registered, just log in with your user name and password.
Express Scripts Online. Once registered with MemberCentral, you can
also get immediate, online access toinformation about your specic
pharmacy benet byvisiting Express Scripts Inc., (ESI), our
pharmacymanagement partner, at www.express-scripts.com.Once there,
youll have access to:Price a Drug Find a PharmacyMail Service
features (which allow you to order rells and renew
prescriptions)
OverviewMail Service PharmacyWith the Mail Service Pharmacy
(administered by ESI), you can enjoy the convenience of having
certain prescriptionsdelivered to you. Depending on your specic
coverage, you can use the Mail Service Pharmacy to order up to a
90-day supply of certain long-term maintenance medications(like
those used to treat high blood pressure), for less than you may
normally pay at a retail pharmacy.Its convenient, cost-effective,
and all information is handled in accordance with our condentiality
policy.If you would like to use the Mail Service Pharmacy, you can
download an order form and nd additional information on our
website. Go to www.bluecrossma.com/pharmacy and choose Mail Service
Pharmacy from the menu on the left-hand side. If youd like our Mail
Service Pharmacy brochure mailed to you, please call 1-800-262-BLUE
(2583).Your Pharmacy Cost ShareOur pharmacy program formulary is
based on a tiered cost share structure. When you ll a prescription,
the amount you pay the pharmacy (your prescription cost share) is
determined by the tier your medication is on. Medications are
placed on tiers according to a variety of factors, including what
they are used for, their cost, and whether equivalent or
alternative medications are available. The pharmacy will advise
youof the amount you owe. Usually, you will pay the leastamount of
cost share for Tier 1 medications and the mostfor Tier 3
medications.Your cost share may include your copayment,
co-insurance, and deductibles. For more about your specic
prescription benets, review the information in your benet
literature, which you should have received when you enrolled in
your plan, or call the Member Service number listed on the front of
your ID card, Monday through Friday, 8:00 a.m. to 9:00 p.m. ET.Your
ID CardYour ID card contains important information about your
pharmacy benets. Be sure to bring the card with you and give it to
your pharmacist when you ll a prescription.A sample ID card is
shown below.3Your Pharmacy Cost ShareOur pharmacy program formulary
is based on a tiered cost share structure.When you ll a
prescription, the amount you pay the pharmacy (yourprescription
cost share) is determined by the tier your medication is
on.Medications are placed on tiers according to a variety of
factors, including whatthey are used for, their cost, and whether
equivalent or alternative medicationsare available. The pharmacy
will advise you of the amount you owe.Usually, you will pay the
least amount of cost share for Tier 1 medications andthe most for
Tier 3 medications.Your cost share may include your copayment,
co-insurance, deductibles,and maximums. For more about your specic
prescription benets, review theinformation in your benet
literature, which you should have received whenyou enrolled in your
plan, or call the Member Service number listed on the frontof your
ID card, Monday through Friday, 8:00 a.m. to 9:00 p.m. ET.Your ID
CardYour ID card contains important information about your
pharmacybenets. Be sure to bring the card with you and give it to
your pharmacistwhen you ll a prescription. A sample ID card is
shown below.SAM SAMPLEXXH123456789MEMBER SUFFIX: 00HMO
BlueTMCopaysOV 15BH 15 ER 40Member Service1-800-000-0000RxBin:
003858 PCN: A4RxGRP: MASASMPL Lr S r Ser ervv Se Serv rv r Se r
Serv rv0- 0-000 000-0 -0 00 000 000 00 00 000 000 00 00 000 000
00RxBin RxBin: 0 : 00385 03858 P 8 P RxBin RxBin: 0 : 00385 038588
RxBin:RxBin: 00 00385 385RxGRP:RxGRP: MM RxGRP: RxGRP: RxGR
RxGR
Top Covered MedicationsTop Covered MedicationsOur pharmacy
formulary includes over 4,000 coveredprescription medications. The
following sample list includes covered medications most commonly
prescribed forour members.This list is up-to-date as of January 1,
2015, and is subject to change at any time. You can nd the most
up-to-date information about a specic prescription medication on
our website at www.bluecrossma.com/pharmacy.Please note that this
is a sample of top prescribed medications based on our standard
formulary. For more information about your specic prescription
benets, review the information in your benet literature, which you
should have received when you enrolled in your plan, or call the
Member Service number listed on the front of your ID card.The
following covered medication list is based on ourstandard
formulary. The tier that is assigned to the drugis the tier used in
a three-tier cost share benet structure.For members with a two-tier
or four-tier cost share benefit structure, please log on to the
Blue Cross and Blue Shield web site at www.bluecrossma.com/pharmacy
and use the Medication Lookup feature.
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, 2015, and is
subject to change at any time.Generic Aspirin (81mg) is covered for
females age 5579 and males age 4579.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 is covered for up to two
90-day supplies per calendar year.Generic Vitamin D is covered for
females of child bearing age and males age 65 and older.Generic
womens contraceptives (e.g. female condoms, sponges, and
spermicide) are covered.
Quality Care DosingQuality Care DosingOur Quality Care Dosing
program helps to ensure that the quantity and dose of medications
you receive comply with Food and Drug Administration (FDA)
recommendations, as well as manufacturer and clinical information.
When you lla prescription for one of the following medications, it
is checked electronically in two ways: Dose ConsolidationChecks to
see whether youre takingtwo or more pills a day that can be
replaced with one pillproviding the same daily dosage. Recommended
Monthly Dosing LevelChecks tosee that your monthly dosage is
consistent with themanufacturers and FDAs monthly
dosingrecommendations and clinical information.We will get your
doctors approval before making any changes to your prescribed
medications.For the most up-to-date list of medications subject
toQuality Care Dosing, along with associated dosing limits, please
visit our website at www.bluecrossma.com/pharmacy and proceed to
the Quality Care Dosing section.Please note: Your doctor may
request an exception fromthe guidelines for medications that are
subject to Quality Care Dosing (when medically necessary).Quality
Care Dosing ListThis list of medications that are in our Quality
Care Dosing program is up-to-date as of January 1, 2015, and may
change from time to time.
Prior AuthorizationPrior AuthorizationYour doctor is required to
obtain prior authorization before prescribing specic medications.
This ensures that yourdoctor has determined that this medication is
necessaryto treat you, based on specic medical standards.For the
most up-to-date list of medications thatrequire prior
authorization, please visit our
website,www.bluecrossma.com/pharmacy, click on Pharmacy Management
Program, and proceed to Prior Authorization.Another part of our
prior authorization program is step therapy. Please refer to page
for a list of medications that require step therapy.Prior
Authorization ListThis list of medications that require prior
authorization is up-to-date as of January 1, 2015, and may
changefrom time to time.19
Specialty Pharmacy MedicationsSpecialty Pharmacy MedicationsBlue
Cross Blue Shield of Massachusetts has set up anetwork of retail
specialty pharmacies to dispense certain medications classied as
specialty. The following is alist of medications that can only be
purchased from oneof the pharmacies in this network in order for
coverageto be available.This list is up-to-date as of January 1,
2015. You cannd the latest information about your medications and
look up pharmacy contact information by
visitingwww.bluecrossma.com/pharmacy.Network Pharmacy
InformationAcariaHealth 1-866-892-1202 www.acariahealth.comAccredo
Health Group, Inc. /CuraScript 1-877-988-0058 www.accredo.comCVS
Caremark, Inc. 1-866-846-3096 www.caremark.comOncoMed, the Oncology
Pharmacy 1-877-662-6633 www.oncomed.netNetwork Pharmacy Information
for Medications Most Commonly Used for Fertility BriovaRx
1-800-850-9122 www.briovarx.comFreedom Fertility Pharmacy
1-866-297-9452 www.freedomfertility.comMetro Drugs 1-888-258-0106
www.metrodrugs.comVillage Fertility Pharmacy 1-877-334-1610
www.villagefertilitypharmacy.comWalgreens 1-800-424-9002
www.walgreens.com/pharmacy/specialpharmacy.jsp
Step TherapyStep TherapyStep therapy is a key part of our prior
authorization program that allows us to help your doctor provide
you with an appropriate and affordable drug treatment. Before
coverageis allowed for certain costly second-step medications,we
require that you rst try an effective, but less expensive, rst-step
medication. Some medications may havemultiple steps.Step Therapy
ListThis list is up-to-date as of January 1, 2015, and is subjectto
change at any time. For the most up-to-date list ofmedications that
require step therapy, please visit our website
www.bluecrossma.com/pharmacy, click on Pharmacy Management Program,
and proceed to Step Therapy.
Non-Covered MedicationNon-Covered MedicationYour pharmacy
program provides coverage for over 4,000 prescription medications.
Most medications on our non-covered list have equally safe,
effective, covered alternatives for treating the same medical
conditions. If a non-covered drug is approved, it will be covered
at the highest tier or cost share. Check with your doctor about
appropriate alternatives if you currently take any of these
medications.Please note: Your doctor may request coverage for a
non-covered medication if no covered alternative is appropriate for
treating your condition.Non-Covered Medication ListThis list of
non-covered medications is up-to-date asof January 1, 2015, and may
change from time to time. For the most up-to-date list of
medications that are not covered and their covered alternatives,
please visit our website, www.bluecrossma.com/pharmacy, click on
Medication Look Up, and proceed to the Medicationsthat are not
Covered section.
Medication Resource List Index
New Medication Approval ProcessNew Medication Approval
ProcessOur Pharmacy and Therapeutics Committee, which ismade up of
pharmacists and doctors of various specialties,reviews the
effectiveness and overall value of new medications approved by the
FDA on an ongoing basis.The Committee provides expertise and advice
to help usgive our members prescription drug options that meettheir
medical needs and achieve desired treatment goals.Approved
medications are added to our formulary as they are approved by our
Pharmacy and Therapeutics Committee throughout the year.While under
review, new medications will not be coveredby your plan. As with
other medications that are not covered, your doctor may request
coverage when medically necessary. If a non-covered drug is
approved, it will be covered at the highest tier or cost share.
Registered Marks of the Blue Cross and Blue Shield Association.
2014 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue
Cross and Blue Shield of Massachusetts HMO Blue, Inc.#14166555-0071
(10/14)