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The is an independent company that administers pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts.
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If you are administering medication to a member in your office or in an outpatient setting, we encourage you to take these steps:
Step | Check member benefits and eligibility. Use a self-service technology like ConnectCenter or contact us.
Commercial members do not have medical benefits for these medications and some employers customize benefits. |
Step |
Determine whether authorization for the medication is required.
Commercial members: View our medical policies for the medication: Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033) Learn how to request prior authorization. Federal Employee Program members: Fax in your written request, along with relevant medical record documentation, to 1-888-282-1315. You must write "Advanced Benefit Determination" on the front of your cover page. Medicare Advantage members: Medicare Advantage Part B Step Therapy Criteria Medicare Advantage Part B Step Therapy Medical Policy 020 Prior authorization is required for these medications when administered in outpatient settings under our Medicare Advantage members’ Part B medical benefits. Medicare Advantage Part B Medical Utilization (MED UM) Policy 125 Learn how to request prior authorization.
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Step | Perform the service and submit your claim. |