Participating Plans -- Special Notes and Contact Information:
Aetna Health, Inc.*
Blue Cross Blue Shield of Massachusetts, Inc.
Boston Medical Center HealthNet Plan
Fallon Community Health Plan*
Harvard Pilgrim Health Care
MassHealth/Office of Medicaid
Neighborhood Health Plan
Network Health*
*Data forthcoming.
Blue Cross Blue Shield of Massachusetts, Inc. (BCBSMA)
Department of Clinical Pharmacy: (800) 366-7778
www.bluecrossma.com
BCBSMA has a list of non-covered drugs for the standard pharmacy benefit. This formulary
guide lists commonly prescribed therapeutic classes and some of the drugs covered
in those classes as of January 2009. BCBSMA has instituted a three-tier benefit design.
Certain drugs require prior authorization, are part of a step therapy program, and/or
are subject to dispensing limits. For specific drug and dose coverage inquiries,
please call (800) 366-7778 (Monday-Friday, between the hours of 8 a.m. and 6 p.m.)
or refer to the website at www.bluecrossma.com.
Boston Medical Center HealthNet Plan (BMCHP)
INFORMEDEX Pharmacy Vendor: (800) 510-8980
www.bmchp.org
BMC HealthNet Plan (BMCHP) is a statewide, provider-sponsored health plan that coordinates health coverage for MassHealth (Medicaid) and Commonwealth Care members. BMCHP has both a two-tier and three-tier formulary design. A prescription is required for all prescription and covered over-the-counter (OTC) medications.
Mass Health and Commonwealth Care Plan Type I members:
- Generic and covered OTC medications -$3 per prescription*
- Brand name medications - $3 per prescription
* Copayments for covered generic and over-the-counter drugs (with a prescription) will be $3 EXCEPT for certain covered generic drugs that members may take for high blood pressure, high cholesterol or diabetes. The copayment for these will be $1. These drugs are called antihypertensives (such as propranolol), antihyperlipidemics (such as simvastatin) and antihyperglycemics (such as metformin). Please call one of the numbers below to find out your copay if you don't know.
Commonwealth Care members plan type II and III:
- Tier I - generic and covered OTC medications
- Tier II - preferred brand-name medications
- Tier III - non-preferred, brand-name medications
Certain medications require Prior Authorization (PA), Step Therapy (ST) or Quantity Limitation (DL) as implied in this guide. Other programs include Mandatory Generic Substitution Program for brand name drugs with AB-Rated generic equivalents, and New-to-Market Program (NTM) for recent FDA-approved drugs, each of which requires preauthorization review. The Specialty Pharmacy Program manages the dispensing of certain high-cost medications.
Refer to www.bmchp.org for formulary information, pharmacy network and mail order pharmacy benefits, clinical guidelines for medication coverage, and prior authorization forms. For additional information, please call BMCHP's pharmacy benefits manager, at Informed Rx, (800) 510-8980.
Harvard Pilgrim Health Care (HPHC)
Corporate Pharmacy Services
(617) 509-9060
www.harvardpilgrim.org
Pharmacy_Services@hphc.org
Harvard Pilgrim Health Care (HPHC) offers an open-design formulary, providing coverage for all FDA-approved prescription medications except those primarily used for cosmetic purposes or to treat weight loss.
Harvard Pilgrim offers two prescription drug programs – one with three tiers and one with four tiers. Both provide member choice and cost savings with lower-cost tiers. In both cases, Tier 1 has the lowest cost-sharing. The higher tiers include non-preferred medications and higher-cost brand name drugs with generic alternatives. The biggest difference is that our 4-tier program includes a cost-saving $5 Tier 1 level. Tier 1 includes many lower cost generics, which contain the same active ingredients as their brand-name counterparts, and saves members money on commonly used prescriptions. Certain drugs may be subject to step therapy, prior authorization and/or may be covered in limited quantities. Copayments will vary according to an individual member's coverage. Please refer to the member's insurance card for individual coverage information.
The drugs listed in this edition of the Massachusetts Outpatient Formulary Guide represent agents that were covered for commercial members at the time of printing. For additional information, please refer to the HPHC Online Formulary at www.harvardpilgrim.org (click on "Providers").
Neighborhood Health Plan of Massachusetts (NHP)
Pharmacy Department
(617) 772-5500 or (617) 772-5565
Or for the most up-to-date information, log onto www.nhp.org,
for Providers.
The drugs listed in this document represent agents that were on NHP's Preferred Drug List (PDL) at the time of printing. Non-preferred brand name drugs are not listed in this edition of the Massachusetts Outpatient Formulary Guide. The list is applicable to all NHP members who have pharmacy coverage, including Medicaid, Commonwealth Care Plan , and Commercial.
The standard drug benefits for most Commercial and Commonwealth Care Plan Types 2, and 3, have three tiers.
- Tier 1 - generic drugs, lowest copayment
- Tier 2 - preferred brand drugs, higher copayment
- Tier 3 - non-preferred brand drugs, highest copayment
The standard drug benefits for Medicaid and Commonwealth Care Plan Type 1 are as follows:
- Tier 1 ($1) - Generic antihyperglycemics
Generic antihypertensives
Generic antihyperlipidemics
- Tier 2 ($2) - for each prescription and refill for other generic drugs and OTC drugs covered by NHP
- Tier 3 ($3) - for each prescription and refill for brand-name drugs covered by NHP
A prescription is required for all prescription and "OTC" medications. When available, FDA-approved generic drugs are to be used in all instances, regardless of "Dispense as Written" indicated. Certain drugs may require prior authorization (PA), step-therapy (ST) or may have a quantity limitation (QL). NHP's Pharmacy and Therapeutics (P&T) Committee reviews all pharmacy programs annually and new drugs for safety, efficacy, side effects and post-marketing reports. While a drug is being reviewed, it is not covered. Please refer to the NHP pharmacy benefit, visit the website at www.nhp.org, or call (617) 772-5500 for more detailed information. Our website also contains the forms required to request prior approval for specific medications. These forms specify the information elements needed to evaluate and process prior approval (PA) requests, and can be downloaded as needed.
Office of Medicaid/MassHealth Review (MAHLTH)
The MassHealth Drug Utilization Program
Phone: (800) 745-7318
Fax (877) 208-7428
www.mass.gov/masshealth/pharmacy
The Pharmacy section of the Office of Medicaid is pleased to participate in the
12th edition of the Massachusetts Outpatient Formulary Guide with the MassHealth
Drug List. The drugs listed are a subset of the complete MassHealth Drug List, which
can be found at www.mass.gov/masshealth/pharmacy
or www.mass.gov/druglist. This site also
contains the forms required to request prior approval for specific medications.
These forms specify the information elements needed to evaluate and process prior
approval (PA) requests, and can be downloaded as needed.
Unlike the other contributors, MassHealth does not have a "Tier" system differentiating
classes of drugs or drugs within classes. Readers will note that MassHealth has
many drugs in the PA category; however, in most classes, there is at least one example
that does not require PA. Also, some drugs have dispensing limitations. When a provider
determines a need that exceeds a dispensing limitation, a PA request needs to be
submitted documenting the necessity for the variance, even if the drug itself does
not require PA.
Medicare Part D
MassHealth members who are also eligible for Medicare Part D must receive their
drug benefit from Medicare. MassHealth will continue to cover some drugs that are
excluded from coverage under Part D for these dually eligible members. Such drugs
include certain prescription vitamins and minerals, certain nonprescription drugs,
benzodiazepines, and barbiturates. The supplemental coverage of these drugs for
the dual eligibles is subject to any existing limitations on coverage for these
classes of drugs for all Medicaid beneficiaries. (If a Medicare Part D plan elects
to cover any of these excluded drugs, the member must receive the benefit from Medicare.)
Inquiries concerning the MassHealth drug list may be directed to the MassHealth
Drug Utilization Review Program at (800) 745-7318.
Disclaimer
Individual plans should be contacted for complete formulary lists or for further information about drug coverage. Formulary information changes frequently. Although the information in this Guide is current as of May 2011, individual plans should be contacted for the most up-to-date information. Inclusion of any drug in a plan's formulary shall not be construed as a commitment on the part of that plan to continue to offer that drug. This Guide should not be used after May 2012.
The information contained in this Guide has been provided by and at the sole discretion of each individual health plan. Formulary information is proprietary information of each plan, and may not be used or reproduced for any purpose without a plan's express permission. The information contained in this Guide is intended to serve only as a resource to the public.
The Massachusetts Medical Society accepts no responsibility for the accuracy and scope of the information contained in this Guide, nor for the acts or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein.
© Copyright 2011 Massachusetts Medical Society. All rights reserved.
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