This article is for all providers caring for our members
Beginning January 1, 2023, we will make changes to our health plans and benefits. Because of these changes, it is always important to check your patient’s Blue Cross ID card and to verify their eligibility and benefits. You can do this using ConnectCenterTM, which has replaced Online Services.
Pharmacy changes for Commercial and Medicare Advantage members
Changes for our Commercial members
Changes for our Medicare Advantage members
Changes for our Federal Employee Program members
We are updating our formularies and our benefits for pharmacy coverage. We’ll also have a new pharmacy benefit manager in 2023 for our Commercial and Medicare Advantage members.
you need to know about our new pharmacy benefit manager
On January 1, 2023, our new pharmacy benefit manager will be CVS Caremark1. To create a smooth transition, we are ensuring that:
Members will receive new ID cards throughout December that will contain updated information that the pharmacy will use to process their claims.
You can tell whether the member has pharmacy coverage with Blue Cross by looking at their member ID card. Look for the Rx symbol on the bottom of their card.
Some employers choose to offer their employees separate prescription drug coverage. If that is the case, the member will have a separate prescription coverage ID card. If they do not have their pharmacy coverage with Blue Cross, we recommend that you ask them to show you that card.
Our large group accounts will have the option of selecting two new plans, while our medium-size group accounts may choose the first of these plan types:
Advantage Blue® Preferred
These Exclusive Provider Organization (EPO) plans offer access to our National BlueCard® network with no out-of-network coverage, except for emergencies. Members are not required to select a PCP or receive referrals to see a specialist.
Network Blue® Select Saver
This HSA-qualified, high-deductible health plan features a limited network of doctors and hospitals that provide high-quality care at a lower cost.
Small group accounts will have the option of choosing one of these new, lower-premium plans:
$0 visits at Limited Services Clinics
To increase convenient access to low-cost, high-quality care, we’re offering employers the option to purchase a rider that will allow members to visit limited services clinics at no cost (deductibles will apply to these services on HSA-compatible, high-deductible plans).
Limited services clinics, such as CVS MinuteClinic, are typically staffed by a professional care team and located within the CVS Pharmacy. They can provide vaccinations and routine health checkups, as well as diagnosis and treatment for simple medical concerns.
Virtual Care Team feature
We are introducing a new virtual primary care feature for most Commercial members starting January 1, 2023. Members can choose a PCP associated with two virtual care vendors: Firefly Health and Carbon Health. The dedicated Virtual Care Team will help manage the member’s health, including mental health. In most cases, the member has no cost share for primary care and mental health services provided by the member’s Virtual Care Team. Deductibles will apply to these services on HSA-compatible, high-deductible plans.
Enrolled members receive a welcome kit with connected medical devices, such as a blood pressure monitor, to use for virtual visits. When in-person care is needed, members have access to their plan’s full network of providers. Their Virtual Care Team can refer members for in-person care, and securely share medical records to ensure continuity of care.
Cost-share Assistance Program
This program allows eligible members to use coupons from medication manufacturers to reduce the cost of eligible, high-cost specialty medications. Once enrolled, most or all of a member’s out-of-pocket costs will be covered, and there will be no need to change where or how the member gets prescriptions.
Breast pump supply mandate
Members will be eligible to receive breast pump replacement parts 90 days after the purchase of a breast pump and every 60 days following that date. These parts will be available at no additional cost to the member when purchased from an in-network durable medical equipment provider. Benefits won’t be available if the parts are obtained from an out-of-network provider.
We’re revising the combined physical and occupational therapy visit limit under the short-term rehabilitation benefit for our standard Blue Care® Elect PPO and Advantage Blue EPO plans from 100 visits to 60. Accounts may continue to customize their visit limit. You can use ConnectCenter to look up visit information, as shown below:
Hearing aid expansion
For certain small group plans, we’re removing the 21 and under age limit for hearing aid coverage that includes $2,000 per hearing-impaired ear every 36 months. There is no change to our hearing aid coverage for our large group plans.
The Affordable Care Act (ACA) Out-of-Pocket Maximum and Internal Revenue Service (IRS) Cost-of-Living Adjustments for 2023
Most health plans must include an out-of-pocket maximum that limits costs for all Essential Health Benefits, including pharmacy. Out-of-pocket costs include copayments, co-insurance, and deductibles. Our standard health plans include an out-of-pocket maximum that’s set at or below the ACA’s limits and IRS’ guidelines for HSA-compatible, high-deductible plans.
Annual out-of-pocket maximums for 2023
|Plan Type||Individual Coverage||Family Coverage|
|HSA-qualified high-deductible health plans||$7,500||$15,000|
|Non-HSA-qualified health plans||$9,100||$18,200|
Transparency in Coverage Billing Code Cost Estimator
We will offer a new real-time cost estimation tool to members to meet the Transparency in Coverage mandate. The Billing Code Cost Estimator will provide members with personalized out-of-pocket cost information and negotiated rates for in-network providers, including:
For 2023, the Billing Code Cost Estimator will provide responses for 500 specific billing codes. In 2024, the tool will include all billing codes and will let the member customize the response by including factors such as units, modifiers, and site of service.
While we fully support the Transparency in Coverage Cost Estimation requirements, we will continue to maintain our cost estimator embedded in our ‘Find a Doctor & Estimate Cost’ tool. This existing tool takes a different approach to cost estimates that we believe more fully represents the experience a member will have when seeking services.
Reproductive and Gender-affirming Care Act
On July 29, 2022, Governor Baker signed the Reproductive and Gender-affirming Care Act into law. It becomes effective on January 1, 2023 as accounts renew. The law:
Lower copayments and cost share changes
Many of our Medicare Advantage plans will include $0 copayments for routine and preventive care, like:
$260 toward over-the-counter health care purchases
Members of our Medicare Advantage PPO Saver and HMO Saver plans will receive a quarterly allowance of $65 for over-the-counter health and wellness items, such as first aid, cold or allergy medication, pain relievers, and vitamins. This allowance must be used in the specific quarter; any unused balance will not be rolled over to the following quarter.
Comprehensive and preventive dental care
We’re expanding the calendar year maximum for members of our PPO Saver and PPO Value plans to $1,000 per year for exams, fillings, and crowns. For our HMO Saver plan, the calendar year maximum will remain at $500 for 2023. For more information, see our News Alert, "2023 Maximum Allowable Charge and Medicare Advantage enhancement" (log in, go to News, and scroll to November 1, 2022).
Coverage for vaccines and lower monthly copayments for insulin
In August, President Biden signed the Inflation Reduction Act of 2022, which includes two provisions that go into effect for Medicare Advantage members on January 1, 2023:
Expanded fitness benefit
We are expanding our fitness benefit to include pool-only facilities. Members have an annual allowance of $150 to $250 toward fitness membership fees, in-person and virtual class fees, and home fitness equipment.
Complimentary access to Learn to Live
All Medicare Advantage members will have access to Learn to Live, an online tool designed to help with mental health. Learn to Live has self-directed, coach-supported programs focused on helping people overcome anxiety, depression, and insomnia.
Changes to telehealth visit coverage
The following changes apply to our Federal Employee Program (FEP) Standard Option, Basic Option, and FEP Blue Focus plans.
To read more on all FEP benefit changes, please visit fepblue.org/plan-brochures.