Understanding Bcbs Medex Network and Policy Changes

If you're a BCBS Medex member, you're likely familiar with the network of healthcare providers that come with your plan. The BCBS Medex network includes over 90% of physicians and 95% of hospitals in the United States.

To navigate this network, it's essential to understand the policy changes that may affect your coverage. One such change is the requirement for pre-authorization for certain procedures, which can be obtained through the BCBS Medex online portal or by contacting their customer service.

The BCBS Medex network is constantly evolving, with new providers and facilities being added regularly. This means that even if you're familiar with your network, it's still a good idea to review your plan documents or log in to the online portal to ensure you have the most up-to-date information.

As a BCBS Medex member, you have access to a vast network of healthcare providers, but it's crucial to understand the policy changes that may impact your coverage.

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Coverage changes can be a bit tricky to navigate. Some medications are no longer covered starting January 1, 2022, including Alinia for anti-parasite treatment, which can be replaced with nitazoxanide.

Your doctor may request an exception if the medication prescribed is medically necessary, but you'll pay the highest-tier cost if approved. This applies to medications like Tecfidera for multiple sclerosis treatment, which can be replaced with dimethyl fumarate.

Here are some medications that are no longer covered:

Note: Some medications may have prior authorization and/or step therapy requirements, as seen with Tecfidera.

As of January 1, 2022, several medications will no longer be covered by our plan.

The following medications will be removed from our formulary: Alinia, Timoptic Ocudose, Omeclamox, Tecfidera, Norgesic Forte, Lyrica, Kuvan, ProAir HFA, ProAir RespiClick, triamcinolone 0.05% ointment, Trianex 0.05% ointment, and Tritocin 0.05% ointment.

If your doctor prescribes one of these medications, they may request an exception if it's medically necessary. If approved, you'll pay the highest-tier cost.

Here are some of the medications that will no longer be covered, listed by class:

Make sure to discuss any concerns with your doctor, who can help you find alternative treatments that may be covered by our plan.

As of July 1, 2021, several medications will no longer be covered by your insurance plan.

The following medications will be removed from the formulary: Allzital 25 mg/325 mg tablets, Oxycodone ER, Oxycontin 10 mg tablets, Oxycontin 15 mg tablets, Oxycontin 20 mg tablets, Oxycontin 30 mg tablets, Oxycontin 40 mg tablets, Oxycontin 60 mg tablets, Oxycontin 80 mg tablets, Azeschew tablets, Minocycline 50 mg tablets, Minocycline 75 mg tablets, and Minocycline 100 mg tablets.

However, covered alternatives are available for these medications, including Butalbital/Acetaminophen 25 mg/325 mg tablets, Xtampza ER 9 mg capsules, Xtampza ER 13.5 mg capsules, Xtampza ER 18 mg capsules, Xtampza ER 27 mg capsules, Xtampza ER 36 mg mg capsules, Mynatal, Mynatal Advance, Mynatal Plus, Prenatabs FA, Prenatabs Rx, Trinate, Minocycline 50 mg capsules, Minocycline 75 mg capsules, and Minocycline 100 mg capsules.

If you're currently taking one of these medications, your doctor may request an exception if it's medically necessary. If the exception is approved, you'll pay the highest-tier cost.

Here's a list of the medications that will be removed from the formulary:

Please note that the covered alternatives for Narcotic Analgesics will be added to the formulary on April 1, 2021.

BCBS Medex has a network of over 1 million healthcare providers across the United States.

These providers include primary care physicians, specialists, hospitals, and other healthcare facilities.

The network is constantly being updated to ensure that members have access to a wide range of healthcare services.

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Encompass Fertility has joined our specialty pharmacy network for fertility medications, effective July 19, 2022. This change applies to plans with the Blue Cross Blue Shield of Massachusetts formulary and the National Preferred Formulary (NPF).

Encompass Fertility can now fill and ship medications in all 50 states, making it a convenient option for those in need of fertility medications. For more information about specialty fertility medications, you can use our Medication Lookup tool.

If this caught your attention, see: Bcbs Approved Medication List

If you have a plan with a three-tier pharmacy benefit, you should be aware that the Blue Cross Blue Shield of Massachusetts formulary has been updated. Certain medications are switching tiers, which may affect your out-of-pocket costs.

Here's a breakdown of the changes to the formulary:

It's always a good idea to check your plan's specific details and consult with your healthcare provider to ensure you're getting the best possible care.

Our network of pharmacies has undergone some changes. AllianceRx Walgreens Pharmacy will join our specialty pharmacy network on January 1, 2024.

This addition will expand our network to better serve members with complex health conditions. If you have a plan with the Blue Cross Blue Shield of Massachusetts Formulary or the Standard Control with Advanced Control Specialty Formulary, you may be affected.

BriovaRx, however, will no longer participate in our specialty pharmacy network as of March 31, 2020. This change applies to most members, but those with Medicare Advantage with a Part D prescription drug plan will still be able to use BriovaRx without interruption.

Here's a list of pharmacies that are part of our network:

Keep in mind that these changes may affect your medication coverage and prior authorization requirements. Be sure to check with your plan administrator for more information.

Policy Updates are a crucial part of staying on top of your healthcare. Here are some important changes to be aware of:

Blue Cross medical policies are updated regularly to ensure that the technologies, procedures, and treatments we cover are evidence-based and effective. Pharmacy medical policies describe how we cover certain medications.

Here are some key updates to look out for:

Some specific policy updates to note include:

Medical policy updates are a crucial part of ensuring that you receive the best possible care. Blue Cross medical policies are developed using evidence-based information to define what treatments are considered medically necessary, not medically necessary, or investigational.

Step therapy policies are being updated to require that you try a less expensive medication before moving to a more expensive one. Your doctor can request an exception if needed.

Prior authorization requirements are also being updated to ensure that your prescribing doctor has determined that a medication is necessary to treat you, based on specific medical standards. This means that you may need to get approval from Blue Cross before starting certain medications.

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Several medical policies are being updated, including the Immune Modulating Drugs Policy (004) and the Injectable Specialty Medication Coverage Policy (071). The Immune Modulating Drugs Policy will move Velsipity from the "Non-Formulary, Non-Preferred Drugs" section to the "Formulary Non-Preferred Drugs" section for the treatment of Ulcerative Colitis.

Here are some specific policy updates:

The Injectable Specialty Medication Coverage Policy (071) will also require prior authorization for new prescriptions starting January 1, 2025, and coverage through the medical benefit will end December 31, 2024.

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Prior Authorization requires approval before coverage is granted for certain medications.

Our plan has a list of medications that need prior authorization, including Fulphila, Granix, and Nivestym, among others.

To find out if a medication requires prior authorization, use the Medication Lookup tool.

The tool will also help you find covered alternatives for non-covered medications.

For medications that require prior authorization, your doctor must first obtain approval before we cover them.

If the pharmacist doesn't fill the prescription, your doctor can contact Blue Cross to request authorization for coverage.

To get approved, one of the following must be true: the member has a diagnosis of cancer, the member is receiving opioids as part of palliative care, or the prescriber says that the amount of opioid prescribed is necessary for adequate pain management.

This safety review doesn't apply to prescriptions written by in-network oncologists, palliative care providers, and pain management specialists.

Here are some specific medications that are exempt from this safety review: Bensal HP, Epiduo, Pliaglis, Prilocaine 7%/Tetracaine 7%, and Sil-k 2” X 5” Pad.

Blue Cross Blue Shield (BCBS) Medex plans have a list of covered medications, known as the formulary. This list changes periodically to reflect new medications, updated coverage criteria, and other factors.

Some medications may require prior authorization, which means your doctor needs to request approval before you can get the medication. For example, medications like Cuvitru, Jesduvroq, and Spevigo require prior authorization for new and existing prescriptions.

Other medications may be subject to step therapy, which means you may need to try a less expensive medication before you can get a more expensive one. Your doctor can request an exception if needed.

The 4Q formulary update for Blue Cross Blue Shield of Massachusetts is a significant change that affects medical plans with pharmacy benefits and Medex plans with a three-tier pharmacy benefit. This update includes changes that were originally scheduled to go into effect on May 1 and July 1.

Certain medications may be added, removed, or have their coverage changed as part of this update. For example, new-to-market medications in the specialty pharmacy network will be covered starting July 1, 2019.

Medications no longer covered starting July 1, 2021, include Allzital 25 mg/325 mg tablets for migraine treatment, and several opioid medications, including Oxycontin and Oxycodone ER. However, a doctor may request an exception if these medications are medically necessary.

The covered alternatives for these medications will be added to the formulary on April 1, 2021, and will be subject to a higher cost tier.

Here is a list of medications no longer covered starting July 1, 2021:

Oxycontin 10 mg tablets

Oxycontin 15 mg tablets

Oxycontin 20 mg tablets

Oxycontin 30 mg tablets

Oxycontin 40 mg tablets

Oxycontin 60 mg tablets

Oxycontin 80 mg tabletsXtampza ER 9 mg capsules

Xtampza ER 13.5 mg capsules

Xtampza ER 18 mg capsules

Xtampza ER 27 mg capsules

Xtampza ER 36 mg capsulesPrenatal VitaminAzeschew tabletsMynatal

Mynatal Advance

Mynatal Plus

Prenatabs FA

Prenatabs Rx

TrinateTetracycline AntibioticMinocycline 50 mg tablets

Minocycline 75 mg tablets

Minocycline 100 mg tabletsMinocycline 50 mg capsules

Minocycline 75 mg capsules

Minocycline 100 mg capsules

The covered alternatives for these medications will be added to the formulary on April 1, 2021, and will be subject to a higher cost tier.

The Medex plan is a supplemental plan that provides additional coverage to your Medicare hospital insurance (Part A) and Medicare medical insurance (Part B). It's administered by Blue Cross Blue Shield of Massachusetts and offered by MIT.

You don't need to choose a Primary Care Provider (PCP) or get a referral to see a specialist. This plan is designed to be convenient and hassle-free.

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There are no copayments required on your part, except for services received in a skilled nursing facility. The only copayments associated with this medical plan are copayments for these services.

To be eligible for the Medex plan, you must have and maintain Medicare Parts A and B, and Medicare must be your primary insurance. You must also live in the U.S. or its territories.

Here are the requirements to be eligible for the Medex plan:

You'll receive a new medical ID card from Tufts Health Plan and a new prescription drug ID card from Express Scripts. You'll also be enrolled automatically in the Medicare Part D Prescription Drug Plan, unless you choose to opt out.

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On October 1, 2020, a change will be made to cover certain medications at no additional cost for members.

This change applies to plans with either the Blue Cross Blue Shield of Massachusetts Formulary or the National Preferred Formulary.

The medications that will be covered at no additional cost are:

This change doesn't apply to grandfathered plans that don't comply with the Affordable Care Act.

We're excited to introduce our new Medication Lookup Tool, which makes it easy to determine which medications are covered by your plan. This tool is a game-changer for anyone who's ever struggled to figure out what's covered and what's not.

With our new tool, you can search for any medication, view medications by strength, and even see how they're dispensed, such as pills, liquids, or injections. This will help you make informed decisions about your care.

You can use the tool to see which medications have additional requirements, like Prior Authorization, Step Therapy, or Quality Care Dosing. This is especially helpful for medications that have specific dosing limits to ensure you're getting the right amount.

Here are some key features of the tool:

Our tool also helps you understand your out-of-pocket costs, which is based on your plan design. Knowing how many tiers your plan has can help you make informed decisions about your care.

For example, some medications have changed their Quality Care Dosing (QCD) limits, which means the quantity and dose of the medication now meet the Food and Drug Administration, manufacturer, and clinical recommendations. To see which medications have changed, you can check out the list below:

Our plans cover a wide range of alternative treatment options for pain management, including over 500 non-opiate medications. These alternatives can be a great option for those who prefer not to use opioids.

We also cover several specialty services that combine therapies to offer individualized treatment for pain management. These services include physical and occupational therapy, chiropractic treatment, pain medicine specialists, TENS units, and acupuncture.

The Alternatives to Opioids section in our Medication Lookup tool, which will be added by the end of December, is a great resource for finding more information on these alternatives. You can also check your pharmacy benefit materials for more information on non-opiate medication coverage.

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If you're a Massachusetts resident, you'll be happy to know that there's no extra charge for partially filling your narcotic or opioid prescription. This is due to a recent change in the "partial fill" law, which allows you to fill the remainder of your prescription at the same pharmacy within 30 days without an additional copay.

Here are some examples of medications that will be covered under our plans, including their 2020 tier levels:

Remember, it's always a good idea to check your pharmacy benefit materials for the most up-to-date information on your medication coverage.

Medications with new quality care dosing (QCD) limits are subject to change to ensure they meet FDA, manufacturer, and clinical recommendations.

The QCD limit for certain medications has been updated, affecting how often they can be covered by your insurance. For example, the QCD limit for Skyrizi 150mg/ml has increased from 1 syringe every 28 days to 1 syringe every 84 days.

Here are some specific medications with updated QCD limits:

It's essential to check the specific medication and its new QCD limit to ensure you're getting the coverage you need.

Dosing limits for certain medications have been increased to give doctors more flexibility when prescribing controlled substances.

The following medications now have a 60-unit limit for a 30-day supply: AMPHETAMINE/DEXTROAMPHETAMINE CAP 5MG ER, AMPHETAMINE/DEXTROAMPHETAMINE CAP 10MG ER, AMPHETAMINE/DEXTROAMPHETAMINE CAP 15MG ER, AMPHETAMINE/DEXTROAMPHETAMINE CAP 25MG ER, METHYLPHENIDATE TAB 18MG ER, METHYLPHENIDATE TAB 27MG ER, and METHYLPHENIDATE TAB 54MG ER.

The following medications now have a 120-unit limit for a 30-day supply: AMPHETAMINE/DEXTROAMPHETAMINE CAP 20MG ER, AMPHETAMINE/DEXTROAMPHETAMINE CAP 30MG ER, and METHYLPHENIDATE TAB 36MG ER.

Here is a list of medications with increased dosing limits:

CGM sensors will continue to be covered by your medical plan's pharmacy benefit.

In March, an article was published stating that coverage for CGM sensors would change, but that decision was later reversed.

We have no information on what specific CGM sensors are covered, as this detail is not provided in the article.

The change in coverage was initially scheduled to take effect on July 1, 2018, but that date has passed without any changes.

If you're taking medications that are dispensed in a supply longer than 30 days, be aware that costs are increasing.

Starting January 1, 2019, you'll 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.

Here are the medications that will be affected by this change:

If you're expecting to fill a new prescription, there are some medications that require prior authorization. This means your doctor will need to get approval from your health insurance before you can get the medication.

For new prescriptions only, certain medications require prior authorization. This includes Breo Ellipt, which is a specific medication that will need approval before it's covered.

This process helps ensure that medications are being prescribed responsibly and that you're getting the best possible care.

If you're taking medications that are dispensed in a supply longer than 30 days, be prepared for higher costs.

Starting January 1, 2019, the cost for these medications will increase 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.

Medications affected by this change include:

If you're taking medications that are dispensed in a supply longer than 30 days, be prepared for higher costs.

Some medications, like fluphenazine decanoate, Lupron Depot Pediatric, and Eligard, will have an adjusted copayment based on the supply length, starting January 1, 2019. For example, if your copayment is $25 for a 30-day supply, you'll pay $75 for a 90-day supply.

You can save money on long-term prescriptions by ordering them through the mail order pharmacy. This can be done through MyBlue or by visiting Express Scripts online, where you can also call them directly at 1-800-892-5119.

To find out if your medication is covered by your plan and what costs you'll incur, use the Medication Lookup tool. You can search for any medication, view medications by strength, and see medications by how they're dispensed.

Medigap costs can be a bit confusing, but don't worry, I've got the lowdown. You'll need to pay a separate premium for Medigap coverage in addition to your Part B premium.

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Here are some costs you might incur with Medigap plans:

It's worth noting that MIT's supplemental health plans are designed to fill the gap left by Medicare, so you'll only need to pay for services that Medicare or the plan doesn't cover.

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Your prescription may be affected by changes to your coverage, so it's essential to check your plan details. Some medications may no longer be covered, while others may be excluded from coverage altogether.

Certain medications are moving to a higher tier under certain pharmacy plans, which may increase their cost. You'll need to review your plan to see if any of your medications are affected.

The quantity and dose of some medications have changed to meet FDA, manufacturer, and clinical recommendations. For example, the QCD limit for Skyzi has been increased to 1 syringe per 84 days for certain formulations.

Here's a list of medications with new QCD limits:

If you have any questions or concerns about your prescription, be sure to reach out to your plan's customer service team for more information.

We have a range of tools and resources available to help you navigate your BCBS Medex plan.

Our Medication Lookup Tool is a game-changer for understanding what medications are covered by your plan. With this tool, you can search for any medication, view medications by strength, and see medications by how they're dispensed.

You can use the tool to find covered alternatives to non-covered medications, which can save you money and hassle. The tool also helps you understand which medications have additional requirements, such as Prior Authorization, Step Therapy, and Quality Care Dosing.

To use the tool, simply go to the Medication Lookup tool. Knowing your plan's tier structure can also help you understand your out-of-pocket costs, so be sure to check that out too.

Here are some key features of our Medication Lookup Tool: