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Medication coverage, auth requirements for Medicare Advantage
March 6, 2020

This article is for prescribers caring for our Medicare Advantage members

We’ve received questions from prescribers and our members about the three changes listed below that we made to our Medicare Advantage members’ medication coverage. Below are reminders of the changes that took effect on January 1, 2020.

Step therapy and prior authorization for medications that you buy and bill

For Medicare HMO Blue and Medicare PPO Blue members who are using their Part B medical benefits, the medications listed below require step therapy. This is detailed in our Medicare Advantage Part B Step Therapy Medical Policy 020.

We cover step 1 medications. Step 2 medications require prior authorization and failure with a step 1 medication before we’ll cover them.

Step 1 medications Step 2 medications
(require prior authorization and previous use of a Step 1 medication)
Avastin Eylea, Lucentis, Macugen
Fulphila, Udenyca Neulasta
Granix, Zarxio Neupogen, Nivestym
Hyalgan, Hymovis, Synvisc Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc, Monovisc, Orthovisc, Supartz Fx, Trivisc,
Inflectra Remicade, Renflexis
Retacrit Aranesp, Epogen, Mircera, Procrit

How to request prior authorization

Please be sure to check the member’s benefits and eligibility before administering these medications. To request prior authorization, please use one of the following methods:

eForm: Massachusetts Standard Form for Medication Prior Authorization Requests eForm
(Click Authorization – Pharmacy)
Phone: 1-800-366-7778
Fax: 1-800-583-6289
Mail: Blue Cross Blue Shield of Massachusetts
Pharmacy Operations Department
25 Technology Place
Hingham, MA 02043

Long-acting opioids require prior authorization

We now require prior authorization for long-acting opioids. Please request prior authorization by completing the Medicare Part D Coverage Determination Request Form.

Symbicort coverage

If you prescribe Symbicort, we do cover it on our Medicare Advantage formulary at a tier 3 copay. However, the new authorized generic option, Budesonide-Formoterol Fumarate, is considered a non-covered brand medication, and will require a formulary exception to cover it. If the formulary exception is approved, it’s covered at a tier 4 copay, so Symbicort is still the lower-cost option.