Pharmacy Programs
Pharmacy Programs
BMC HealthNet Plan uses a number of pharmacy programs to promote the safe and appropriate use of prescription drugs. All drugs that belong to a program have clinical guidelines (like current health condition) that must be met before the Plan will cover it. Drugs that belong to a pharmacy program are indicated on the BMC HealthNet Plan Formulary.
If a provider feels that it is medically necessary for a member to take a drug managed under one of our programs, he/she may submit a request to BMC HealthNet Plan using the appropriate prior authorization form. BMC HealthNet Plan will review the prior authorization request using the Medication Exception Process. If the request meets criteria, BMC HealthNet Plan will cover the drug. If the request is denied, the member and the authorized appeal representative have the right to appeal the decision.
- Prior Authorization Program
The Prior Authorization Program requires that BMC HealthNet Plan members meet specific clinical conditions before a drug can be covered.
View Clinical Guidelines and Prior Authorization Forms
- Step Therapy Program
The Step Therapy program requires that members first try one drug to treat a medical condition before we will cover another drug for that condition. If the first level treatment is not tried, prior authorization is required.
View Clinical Guidelines and Prior Authorization Forms
- Mandatory Generic Substitution Program
The Mandatory Generic Substitution Program requires a member to try an “AB rated” generic drug before its brand counterpart would be covered. The Food and Drug Administration (FDA) has determined certain generic drugs are therapeutically equivalent (“AB rated”) to their brand counterparts. This means that the “AB rated” generic drug is as effective as its brand name drug. Massachusetts law also requires the dispensing of the “AB rated” generic drug, unless the provider indicates the brand is medically necessary.
- New-to-Market Medication Program
BMC HealthNet Plan reviews new drugs for safety and efficacy before we add them to our formulary. New drugs require prior authorization until they are reviewed by our Pharmacy and Therapeutics Committee, which is composed of doctors, pharmacists and other healthcare professionals.
-Quantity Limitation Program
The Quantity Limitation Program ensures the safe and appropriate use of some medications by covering a specific amount that can be dispensed at one time. Quantities greater than the specified amount require prior authorization for coverage.
- Specialty Pharmacy Program
The Specialty Pharmacy Program requires that some drugs be supplied by a specialty pharmacy. These drugs include injectable and intravenous drugs that are often used to treat chronic conditions, like Hepatitis C or multiple sclerosis, which require additional expertise and support. Specialty pharmacies have knowledge in these areas and can provide additional support to members and providers.
- Ascend SpecialtyRx 1-800-850-9122
- Curascript 1-888-773-7376
- Accredo Therapeutics 1-866-289-7577
Download Pharmacy Specialty Prescription Guide
View Clinical Guidelines and Prior Authorization Forms
