PCP $0 Cost Sharing

All PCP visits (including sick visits) will now have a $0 copay for dates of services on or after 1/1/25.

Tiering of ASC/OP Hospital Cost sharing

Please continue to check member benefits to see if their plan now is part of a tiered cost sharing. 

Inpatient acute/MH care benefit period 

The inpatient acute/MH care benefit period is moving to a per admission and a 5 day copay structure for both inpatient acute and mental health stays.

Radiation Therapy benefit change

Radiation Therapy benefit is moving to a 20% coinsurance. 

Covered Acupuncture 

As a reminder, it is important for all acupuncture providers to check member eligibility and benefits when the new year approaches as some members may change their plans. Acupuncture benefits vary across all Medicare plans.

Movement of Telemedicine cost sharing to match office cost share

All services rendered as telemedicine on or after 1/1/25 will apply the member’s in-office copay. 

Vision Hardware Allowance 

The following Medicare Advantage plans will experience an enhancement to the existing vision hardware benefit allowance on 1/1/25: 

• BlueCHiP for Medicare Extra - $400 allowance
• BlueCHiP for Medicare Value - $250 allowance 
• NEW! BlueCHiP for Medicare Access - $300 allowance

Introduction of New Plan – BlueCHiP for Medicare Access

2025 will mark the launch of a new low-income plan in place of the ACCESS program. This plan will be named Access and has $0 benefits for those who qualify for Extra Help, also know as Low-Income Subsidy. 

Elimination of Individual HealthMate PPO but continuation of Group HealthMate PPO

BCBSRI will be eliminating the Individual HealthMate PPO Medicare Advantage Plan. Group HealthMate will continue. 

Current HealthMate PPO members will need to actively enroll in a new plan during the Annual Enrollment Period (AEP) or they will drop to Original Medicare and not have Part D coverage. Members will also have a Special Enrollment Period (SEP) to enroll in a new plan but if they fail to make an active selection before 12/31/24, they will have a lapse in Part D coverage. 

Members who choose to move from HealthMate PPO to a BlueCHiP for Medicare plan, will need referrals for services as of dates of service of 1/1/25. Referrals can be entered for the members prior to 1/1/25, as long as the member has selected their new HealthMate PPO plan. PCP’s will need to change the “As of” date from the date of entry to 1/1/25 as that is when the new product will be active for the member. If the member is not active in BCBSRI’s system at the time of entry, the member will not be found. 

Elimination of transportation for many plans

Transportation will only be an offered benefit for members on a low-income plan. Transportation is available for Access Plans (12 one-way rides) and BlueRI for Duals D-SNP plan (72 one-way rides). 

Elimination of Papa Pals for all plans 

We have eliminated the Papa Pals for all Medicare Advantage plans effective on 1/1/25. 

2025 Pharmacy Changes   PBF

Tiering and Formulary updates for Medicare Members: 

• 470 Drugs moving off Formulary 
• 936 Drugs moving to Higher Tiers

Tiering Changes

• 137 drugs moving from Preferred Generic to Generic 
• 38 drugs moving from Preferred Generic to Preferred Brand tier 
• 320 drugs moving from Generic to Preferred Brand tier 
• 125 drug moving from Generic to Non-Preferred Brand tier 
• 282 drugs moving from Preferred Brand to Non-Preferred Brand tier 
• 12 drugs moving from Preferred Brand to Specialty tier 
• 22 drugs moving from Non-Preferred Brand tier to Specialty tier
• Members have rights to the tier exception process for Tiers 2-4

Other Changes

• 38 drugs added to formulary
• 96 drugs moved to lower tiers

For a detailed list of changes, please click here.

For drugs that are move off the formulary, where appropriate, please consider switching members to a covered alternative. For members who cannot utilize a covered alternative please request a coverage exception through Prime Therapeutics. Members impacted by negative formulary changes will be eligible for a transition fill during the first 90 days of the new plan year to allow time for medication changes and/or the coverage exception process. 

Coverage Exceptions

You can ask us to make exceptions to our coverage rules. There are several types of exceptions that you can ask us to make:

• You can ask us to cover a drug that is not on our formulary.
• You can ask us to waive a restriction to a drug that is on our formulary.
• You can ask us to change coverage of a drug to a lower cost-sharing tier. For example, changing a non-preferred drug to a preferred drug cost-share.

How fast will a decision be made?

For a coverage determination, our Plan is required to provide a decision within 72 hours of receiving the prescribing physician's supporting statement. However, if a member’s health requires a faster decision, you can request an expedited coverage determination, and we will provide you a decision within 24 hours after we get the prescribing physician's supporting statement.

Use the following link to start the exceptions process:

Helping People get the Medicine They Need | CoverMyMeds

2025 Exception reviews can be submitted as of November 1, 2024.

Helpful Online Resources 

Did you know that all our Medicare formularies and utilization management (UM) criteria are available online? The formulary is a great tool to help members and providers understand what drugs the plan covers, which of these drugs have UM edits, such as prior authorization, quantity limit, and/or Step Therapy, and which drugs in the same therapeutic category do not have UM. 

Click the below link to explore our formularies and UM criteria:

Pharmacy | Blue Cross & Blue Shield of Rhode Island (bcbsri.com)