This article is for all providers caring for our members
Beginning January 1, 2025, we will make changes to our health plans and benefits. It is important to always check your patient’s Blue Cross ID card and to verify their eligibility and benefits.
We are updating our formularies and medication benefits. In an August 30 News Alert and subsequent October 14 update, we announced changes to our members’ benefits and coverage for their medications including:
To access our News Alert, log in and go to News. Look for the News Alert (indicated with an exclamation mark) dated August 30: "Medication coverage changes starting Jan 1."
Starting in 2025, members with Medicare Part D drug costs will be eligible for a new payment option called the Medicare Prescription Payment Plan. This will help members with Medicare drug coverage manage their out-of-pocket costs by spreading them across the calendar year (January – December). It does not change or lower their prescription costs. Members need to opt into this payment plan (at no additional cost). Feel free to share the fact sheets below with your patients:
Fact sheet: What’s the Medicare Prescription Payment Plan (English version)
Fact sheet: What’s the Medicare Prescription Payment Plan (Spanish version)
For inpatient admissions starting on or after January 1, 2025, if a commercial member’s coverage ends during their inpatient care, we will cover their stay through the last date of coverage unless otherwise required by law. This change aligns with industry standards, will not impact admissions prior to January 1, 2025, and will not apply to Medicare Advantage or Federal Employee Program (FEP) members.
We’re offering new benefit options to self-insured employer plans. They may choose to offer a benefit with $0 cost for a set number of PCP sick and mental health or substance use visits for any enrolled dependents on the plan other than the subscriber and spouse. This includes children, young adults through age 26, and disabled children of any age. Members with Saver plans must meet their deductible first, then any copayment or co-insurance will be waived for the rest of the year.
Self-insured employers may also choose to reduce the PCP and mental health or substance use office visit copayment for dependents, while subscriber and spouse are subject to the higher standard copayment. By reducing or eliminating cost share, these family-friendly offerings encourage members to seek care when it’s needed most.
We’re refreshing the HMO Blue Select limited network in 2025 to include more virtual care provider options. Members with this limited network HMO plan will also have virtual PCP benefits and may be eligible for $0 copayments on certain services like mental health visits, acupuncture, and visits with a chiropractor.
Providers can get information about the HMO Blue Select limited network on our Limited Networks page.
Our self-insured employers may choose to offer the following benefits to their employees and their families:
Last year we introduced a program through Hinge Health for our commercial members in fully insured accounts with chronic back and joint pain. Now, in partnership with Hinge Health, we’ll offer our self-insured employers Hinge Health’s Digital Musculoskeletal Clinic: a new, inclusive digital solution designed to meet a variety of musculoskeletal needs, such as prevention, chronic care, acute care, & post-surgery recovery. It aims to help members manage pain through a coach-led experience using proven, non-surgical care guidelines.
Self-insured employers may choose to include the CVS Weight ManagementTM program as part of their pharmacy benefits. We may reach out to prescribers of these medications if your patient has an active authorization for an anti-obesity medication. The patient must enroll in the program for continued coverage.
The program is available to members 18 years or older with an approved prior authorization for an anti-obesity medication or who are new to taking medication. It is designed to complement the care members receive from their health care providers and provide additional support for them in using weight loss medications.
Members will need to engage and actively participate in the program to receive continued coverage of their anti-obesity medication.
Self-insured employers with 500 or more employees now will have access to two new Teladoc offerings. The Chronic Condition Plus program is designed to help individuals with several chronic conditions such as diabetes, pre-diabetes, and hypertension. The program will help manage their conditions through personalized care plans, virtual consultations with healthcare professionals, and continuous monitoring through connected devices. The Weight Management program is designed to help individuals achieve sustainable weight loss through personalized coaching and nutritional guidance.
In 2025, we will:
The Flex Card functions like a debit card. Blue Cross will auto-load money to use on eligible products and services.
We will lower the copayment or cost for the following services:
For members who need a colorectal cancer screening exam, we will waive the outpatient surgery copayment if a polyp or other tissue is found and removed during the exam.
We’re removing authorization for our Medicare HMO Blue members receiving in-network home health care services. (We do not currently require authorization for Medicare PPO Blue).
This includes home health care services provided by a Blue Cross Blue Shield of Massachusetts contracted agency, such as skilled nursing care; physical, occupational, and speech therapy, social work, and home health aide services.
Read more in our November 1 News Alert by logging in and going to News. Look for the headline, “Medicare HMO Blue members no longer require auth for home health care.”
We’re increasing copayments for:
For all Medicare Advantage members, we will change the dental frequency for periodic or routine oral exams and routine cleaning, scaling, and polishing of teeth from three times each 12 months to three times per calendar year.
For our Medicare Advantage HMO Saver and PPO Saver members, we will increase the Dental Maximum Allowance to $1200 and $1500, respectively.
For Dental Blue 65 members, we will change the allowed frequency for certain benefits as follows:
Service | Current frequency | Frequency as of January 1, 2025 |
---|---|---|
Routine cleanings | Three times in 12 months | Three times per calendar year |
Routine exams | Three times in 12 months | Three times per calendar year |
Enhanced Dental Benefits: Routine Cleanings | Four times in 12 months | Four times per calendar year |
Enhanced Dental Benefits: Periodontal Maintenance Cleanings | Once every three months | Four times per calendar year |
Enhanced Dental Benefits: Oral Cancer Screenings | Once every six months | Two times per calendar year |
Enhanced Dental Benefits: Fluoride Treatment | Once every three months | Four times per calendar year |
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