Provider Central

$0 cost for a set number of visits with a licensed dietician nutritionist

We’re offering large group accounts the option to waive all costs on non-Health Savings Account (HSA) qualified high-deductible health plans for a member’s first one, three, or six outpatient visits (in person and virtual) with a licensed dietician nutritionist. After a member uses all of their $0 cost visits, their standard costs will apply.

Increasing access to diagnostic breast cancer screenings

In accordance with Massachusetts legislation, effective January 1, 2026, we’ll cover the following diagnostic services with at $0 for fully insured plans:

• Mammograms
• Breast MRIs when medically necessary
• Breast ultrasounds when medically necessary

This is in addition to the routine mammograms and routine breast MRIs we already covered at $0. All breast ultrasounds and breast MRIs remain subject to prior authorization where applicable.

The IRS has also expanded guidelines for high-deductible health plans (HDHP), allowing the following preventive services to be covered without meeting the deductible:

• Over-the-counter contraceptives
• Breast cancer screenings*
• Diabetes management such as glucose monitors and insulin

IRS guidelines do not mandate coverage of these services. HDHPs can choose any combination of these preventive options so be sure to check member benefits and eligibility.

*Per federal regulations, breast imaging for members who already have an active breast cancer diagnosis is not screening, so deductibles will apply.

The passage of the Reconciliation Bill and what it affects

Telehealth services: We will offer an optional benefit deductible waiver for all telehealth services for fully insured accounts. This waiver would be offered as an optional benefit rider.

Direct primary care services: The monthly fees associated with direct primary care services are now considered qualified medical expenses that are eligible for Health Savings Account (HSA) reimbursement.

Pharmacy coverage 

• As previously communicated, starting on January 1, 2026 and as members renew their benefits throughout 2026, GLP-1 medications will only be covered for type 2 diabetes. This exclusion from our pharmacy benefit means the member will no longer have coverage for GLP-1s for weight loss¹—even if we’ve covered the medication in the past or it’s been authorized. The only exception will be for members whose employer purchases a rider to continue coverage. Read more about this change.
• With this benefit exclusion, we’ll now have two new formularies for members who no longer have coverage for GLP-1s for weight loss:
  • Members previously using the Blue Cross Blue Shield of Massachusetts Formulary will transition to Blue Cross Blue Shield of Massachusetts Formulary – Focused.
  • Members previously using the Standard Control with Advanced Control Specialty Formulary, will transition to Standard Control with Advanced Control Specialty Formulary – Focused.
• To support members who will no longer have coverage for GLP-1s for weight loss, we’ll offer self-insured accounts (100+) the opportunity to purchase Teladoc’s Comprehensive Weight Care program. The program includes access to:
  • Self-pay, Food and Drug Administration (FDA) approved non-compounded GLP-1 weight loss medications at a program-based rate and/or other medications as discussed with their provider.
  • Lifestyle management support with health coaches and dietitians to drive healthier behaviors in alignment with four pillars of cardiometabolic health (nutrition, activity, sleep, stress management/mental health).
  • Regular phone check-ins to monitor progress including unlimited one-on-one sessions with dedicated health coaches.
  • Ability to receive prescribed weight loss medications directly by mail for convenience.
• We also announced changes to the Blue Cross Blue Shield of Massachusetts formulary, medical policy updates, and changes to the Standard Control with Advanced Control Specialty Formulary. We posted details about this change in October. Sign in to your Provider Central account and scroll to Medication coverage changes starting Jan 1. Notable changes to the Blue Cross Blue Shield of Massachusetts formulary include:
  • Entresto will be removed from Heart Failure, Chronic Kidney Disease, and Hypertrophic Cardiomyopathy (HCM) Policy 063 and will move from Non-Preferred Brands tier to non-covered. Prior authorization will no longer be required for Entresto or sacubitril/valsartan.
  • OneTouch test strips will be non-covered and we will cover Accu-Chek products as alternatives. Affected members who will be notified about their test strips will receive information on how to get a compatible Accu-Check meter at no additional cost to help them make the switch to the covered product.

1. We’re also benefit excluding the GLP-1s for weight loss (Saxenda [liraglutide injection], Wegovy, Zepbound) for other clinical indications, such as heart disease prevention.

Brand medication prices may change for some in 2026

We’re changing the way medication rebates are applied to members filling prescriptions for brand-name medications (non-specialty and specialty).

• This change means that any discounts or rebates available for medications will be applied at the point of sale, directly affecting commercial members with deductible or co-insurance plans who also have our pharmacy benefits. This may result in higher or lower out of pocket costs, depending on the specific medication.
• In the event a member’s cost increases, members are encouraged to speak to their health care providers about covered, lower cost options. Other options include talking to their pharmacist about discount services that may be available or checking with the drug manufacturer about assistance programs.

National dataset will be used to develop new plans and products

The Blue Cross Blue Shield Association recently introduced the Blue Cross Blue Shield Axis^® Provider Insights (Provider Insights). This new national dataset enables Plans to assess providers across 20 specialties on measures of quality, appropriateness, and cost/efficiency at the individual NPI level. Provider Insights was developed by the Blue Cross Blue Shield Association, Blue Health Intelligence, and Motive Medical Intelligence.

Using this dataset, along with Blue Cross Blue Shield of Massachusetts data, we have placed providers into three performance categories based on their overall performance compared to other providers in the same specialty. Providers in those 20 specialties were notified by Blue Cross Blue Shield of Massachusetts of their categories in August. All other providers in the network are placed into category 1.
Read more on our BCBS Axis Provider Insights page.

Categories

What’s next?

Blue Cross Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc., and Massachusetts Benefit Administrators LLC will use these categories in the development of new and evolving products and solutions.

In 2026, we are introducing the first of these solutions that incorporates these categories. Coupe PPO/EPO is an alternative health plan available to certain employers (or accounts) that simplifies searching, selecting, and paying for care. When searching for care, members are presented with an all-inclusive copay based on a provider’s category—taking the guesswork out of expected healthcare costs and allowing members to select from the most cost-efficient providers.

More information will be available when we have accounts that have purchased a Coupe plan.

We’ll no longer offer Medicare PPO Blue SaverRx

Our Medicare PPO Blue SaverRx plan will no longer be available. To avoid any disruption in coverage, we notified members in October of their enrollment options and how to select a new plan by December 31, 2025.

Members who do not elect a new plan by December 31, 2025 will be moved to original Medicare effective January 1, 2026. We will also offer members a special enrollment period to elect a new plan by February 28, 2026; however, this will result in a gap in their Part D coverage.

Members who choose to move from a PPO to HMO plan will have to select a PCP for care and may call your office to inquire about PCP availability if you participate in our Medicare Advantage HMO network.

New Medicare PPO Blue EssentialRx

In 2026 we’re offering a new Medicare PPO Blue EssentialRx plan to members. This low-cost plan features a comprehensive dental benefit. We have included a sample of the Medicare PPO Blue EssentialRx Blue Cross member ID card (shown below) for reference.

Changes to our Flex Card

Medicare Advantage members can use our Flex Card to securely and easily access some of their plans’ benefits, such as qualifying fitness, weight loss, and over-the-counter products. In 2026, we’ll make the following changes.

• The over the counter (OTC) allowance will be $50 per quarter for Medicare HMO Blue SaverRx. The allowance must be used in the specific quarter. Balances will not roll over.
• We’re removing in-home support, and the combined dental, vision and hearing allowance. Members may access their routine dental, vision, and hearing benefits using their Blue Cross ID. 
• For members with diabetes, we’re increasing the reward for completing their retinal eye exam. Members who complete their diabetic retinal eye exam will be rewarded $50 through their Flex Card. Members will also be allowed to complete their retinal eye exam once per calendar year instead of once per every 12 months.