Provider Central

This article is for primary care providers, allergists, and pulmonologists caring for our members

Asthma and allergies can affect anyone, but the impact can vary based on race, ethnicity, and income. You play a crucial role in helping your patients with asthma by making sure they understand their triggers, medications, and treatment plan.

We’re making it easier for patients to access their medications

Tier change: Moving certain inhalers to a lower-cost tier
To help lower our members’ out-of-pocket costs for their inhalers and improve adherence to their controller medication, we’re updating the Blue Cross formulary ¹. Starting on July 1, 2024, the single-ingredient corticosteroid inhalers listed in the table below will move to a lower-cost tier.  

Removing prior authorization
We’re also updating our medical policy 011: Asthma and Chronic Obstructive Pulmonary Disease effective July 1, 2024 to remove prior authorization for Breyna and other generics of budesonide/formoterol.

This will help to reduce administrative burden for you and offer fast access to these products for our members, particularly in acute situations. These medications will continue to have a quantity limit of two inhalers per 30 days.

How you can improve patient outcomes

• Be sure to create an asthma action plan with your patient so they understand their triggers and the appropriate medication to take.
• Share resources that are culturally appropriate and in the patient's preferred language.
• Practice shared decision making with your patients to better understand their individual care preferences and concerns, while building a stronger patient-provider relationship.
• Carefully explain the difference between controller and reliever medication and discuss why controller adherence is important.
• Prescribe a long-term controller medication and provide patient reminders for refills.
• Limit the number of refills on reliever medications to no more than two. If a member requests additional refills, contact them to ensure they’re taking their controller as prescribed, and that it's working for them.

Code claims to exclude patients from asthma quality measures

Certain comorbid conditions, like COPD and emphysema, can exclude members from the asthma medication ratio measure. Avoid coding asthma if the diagnosis is for an asthma-like symptom. Review the conditions below to see if your patient should be excluded.

Using the exclusion codes can eliminate the need to submit patient medical records during HEDIS record collection, saving your staff time and resources.

Note that the list above is not exhaustive, but a sample of diagnosis codes that may be used.

Resources

• Adult Asthma Action Plan (English or Spanish)
• Child Asthma Action Plan (English or Spanish)
• Medical policy 011: Asthma and Chronic Obstructive Pulmonary Disease (will be updated on July 1, 2024 as noted above) 
• Medication Lookup tool for providers (Blue Cross Blue Shield of Massachusetts formulary)

1. The Blue Cross formulary is used by commercial members with a medical plan that includes pharmacy benefits and group Medex members with a three-tier pharmacy benefit. For FEP members, these medications are:

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