Provider Central

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:

• HMO Blue New England $1,500 with Copayment
• HMO Blue New England $3,000 with Copayment

$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.

Short-term rehabilitation

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

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:

• Provider name and demographics
• Location information
• In-network allowed amount
• Member’s out-of-pocket cost (deductible, copayment, coinsurance)
• Member accumulators toward deductible and out-of-pocket maximum
• List of services bundled in the payment (if applicable)
• Notice that referral or authorizations apply (if applicable)
• Out-of-network allowed amount

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:

• Mandates coverage for abortion and abortion-related care without cost share for fully-insured members. (Accounts that are church or church-controlled organizations may opt out.) Deductibles will apply to these services for high-deductible health plans, consistent with federal rules for HSAs.
• Provides legal protections around abortion, abortion-related, and gender-affirming care.
• Does not add new mandates related to gender-affirming care.

Lower copayments and cost share changes

Many of our Medicare Advantage plans will include $0 copayments for routine and preventive care, like:

• Outpatient labs and diagnostic tests
• Primary care visits
• Prescription drugs
• Routine dental visits
• Routine vision and hearing exams

$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:

• Coverage of adult vaccines at $0 copayment
• $35 monthly copayment for insulin

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

• Copayments for physical therapy, occupational therapy, and speech therapy will now match the copayment for in-person visits, allowing members to see clinicians from the comfort of home.
• We will discontinue the special supplemental telehealth benefit for chronically ill members (those with five or more chronic conditions) as of January 1, 2023. This means we’ll no longer apply $0 copayments for telehealth visits for these members. 

• We’ll cover medically necessary bariatric surgery beginning at the age of 16. Previously, this benefit was limited to individuals ages 18 and older.
• We’ll no longer limit the number of non-full sibling donor screening tests for transplants. Previously, we limited non-full sibling donor test screenings to three.
• We will cover medical foods for the treatment of inborn errors of amino acid metabolism regardless of age. Previously, we limited this to individuals under the age of 22.
• We will provide coverage for weight loss medications to treat obesity when obtained through one of our pharmacy drug programs.
• We’ll cover one year of sperm and egg storage for those individuals facing iatrogenic infertility. Prior approval is required.

• We now require prior approval for stereotactic radiosurgery and stereotactic body radiation therapy.
• We now require prior approval for certain high-cost drugs obtained outside of a pharmacy setting.