CurrentBlue Cross Blue Shield - MassachusettsPolicy 071

Injectable Specialty Medications — Pharmacy Benefit Coverage Criteria

Defines which injectable specialty medications are covered through Blue Cross Blue Shield of Massachusetts pharmacy benefit, ordering and payment expectations, and who the policy applies to (commercial members, excluding certain Medicare and federal plans).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyInjectable Specialty Medications — Pharmacy Benefit Coverage Criteria

Policy CodePolicy 071

Change TypeMedication list additions and product clarifications

Effective Date

Next Review Date

Key ActionPrescribers must request prior authorization where required and route specialty injectable medications through an in‑network specialty pharmacy per member benefits.

SourceLink

POLICY UPDATE CHANGES

Added Imuldosa, Ustekinumab-AAUZ, Starjemza, Adalimumab-bwwd, Hymovis One to the medication list.

Clarified Cosentyx formulation to SC.

Added multiple adalimumab biosimilars and updated adalimumab product listings.

pharmacy benefit onlyPharmacy benefit only

commercial membersApplies to

MA/FEF/supplementExclusions

3/15/2026

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Coverage Criteria — Pharmacy Benefit Routing

Pharmacy Benefit Coverage Conditions

Covered when filled through an in-network specialty pharmacy and member's benefits permit

Pharmacy benefit coverage conditions: Medication is listed on the policy's 'List of Medications Covered Only Under the Pharmacy Benefit' AND the prescription is filled through a specialty pharmacy in Blue Cross Blue Shield of Massachusetts' network (exceptions noted for specific medications on the medication list).

Providers must verify member eligibility and benefits; inclusion on the list does not guarantee coverage for all members.

This policy does not apply to members enrolled in Medicare Advantage, the Federal Employee Program (FEP), or members with Medicare Supplemental Plans. Footnotes clarify that the pharmacy-only rule does not apply when a medication is administered in the emergency room, as an inpatient, at a surgical day care facility, in an ambulatory surgery center, or through home infusion therapy or dialysis.

Inclusion of a product on the policy’s “List of Medications Covered Only Under the Pharmacy Benefit” is not a guarantee of coverage. Coverage depends on the member’s specific pharmacy benefits; some members may not have coverage for particular medications listed. Providers should verify member eligibility and benefits before assuming coverage.

Coding and Applicability

No CPT/HCPCS/ICD codes listedmixed

No codes listed

Policy applicability

Benefit applicabilityApplies to the pharmacy (Rx) benefit; not the medical (MED) benefit

Member typesApplies to commercial members (Managed Care HMO/POS, PPO/EPO, Indemnity)

Exceptions and limitationsExceptions to the pharmacy-only rule are noted on the medication list (specific Massachusetts provider buy-and-bill exceptions may apply)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Some medications in this policy may require prior authorization, step therapy, or Quality Care Dosing. Prescribers must request prior authorization when applicable before coverage will be provided.

Pharmacy Operations: Tel: 1-800-366-7778 • Fax: 1-800-583-6289
Policy last updated: 3/15/2026
Applies to Commercial Members with the BCBSMA formulary: Managed Care (HMO/POS), PPO/EPO, Indemnity

Step Therapy

Step Therapy / Program Applicability

Certain drugs may be subject to step therapy or other pharmacy management programs. Check the member's benefits and use the Medication Lookup tool for specific coverage rules and program applicability.

Medication Lookup for Providers: bluecrossma.com/provider
Medication Lookup for Members: bluecrossma.com/medications

Policy Background

This policy is administrative and describes how injectable specialty medications are routed for coverage and which medications are covered under the pharmacy benefit. It does not address clinical effectiveness or clinical treatment criteria; providers should consult clinical guidelines and confirm member benefits and any applicable clinical programs when making treatment decisions.

Definitions — Specialty Pharmacy & Ordering

Specialty pharmacy

DefinitionAn in-network retail specialty pharmacy designated by BCBSMA to dispense medications covered under the pharmacy benefit that require special handling, distribution, or monitoring

Network requirementMedications included in this policy are covered under the member's pharmacy benefits only when filled through a specialty pharmacy in our network; exceptions are noted on the medication list

Prescription requirementA valid prescription from a licensed health care provider is required to fill these medications

Ordering and payment categories

Home (self‑administered)Prescriber must order the medication through an in‑network retail specialty pharmacy; member is responsible for prescription cost sharing (copay, deductible, co‑insurance)

Home infusion therapy

Step Therapy and Program Rules

Program	Guidance
Step therapy	Some medications may be subject to step therapy; check member-specific programs and the Medication Lookup tool to determine applicability. Verify member benefits and any program requirements before prescribing.
Benefit applicability	Policy applies to the pharmacy (Rx) benefit for commercial members (HMO/POS, PPO/EPO, Indemnity). Confirm whether the member’s plan includes step therapy requirements.
How to confirm	Contact Pharmacy Operations (Tel: 1-800-366-7778; Fax: 1-800-583-6289) or use the Medication Lookup tool to determine if a specific drug is subject to step therapy for the member.

Site of Care Ordering Rules

Note

Site‑of‑care ordering and routing

Medications intended for self‑administration at home must be ordered through an in‑network retail specialty pharmacy. Medications administered in a doctor's office should be ordered through an in‑network retail specialty pharmacy for delivery to the provider's office or outpatient clinic; medications administered by a home infusion therapy provider require prior authorization and referral to a home infusion therapy provider who procures and administers the medication.

Biosimilar and Product Listings

Billing Rule

Stelara, Adalimumab — biosimilars listed

Stelara biosimilars and multiple adalimumab products (including newly added adalimumab‑bwwd effective 3/15/2026) are listed on the pharmacy‑only medication list; see the medication list and policy history for specific product entries and effective dates.

Adalimumab-bwwd added to the list on March 15, 2026
Policy history notes addition of Stelara biosimilars and updates to adalimumab products (6/2025)