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. 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.
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
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
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.
View Clinical Guideline
Submit PA Form (Fax)
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 health care professionals.
View Clinical Guideline
Submit PA Form (Fax)
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.
View Clinical Guideline
Submit PA Form (Fax)
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.
View Clinical Guidelines and Prior Authorization Forms
