Tag: Drug Coverage
Medicare GLP-1 Bridge
Centers for Medicare & Medicaid Services (CMS)
Information for Prescribers
Eligible Medicare beneficiaries may now get certain GLP-1 medications for $50.00
Eligible Medicare beneficiaries may now get certain GLP-1 medications for $50 per month through the Medicare GLP-1 Bridge, a new CMS initiative designed to expand access to innovative treatments and test the impacts of increased access to GLP-1 drugs for weight management on the Medicare program
BCBS Pharmacy Qtrly Updates for January 2026
Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2026 – Part 1
Highlights for Aetna OfficeLink Updates
Claim and Code Review Program (CCRP) update
Starting December 1, you might see new claim edits
This update applies to both our commercial and Medicare members.
Beginning December 1, 2025, you may see new claim edits. These are part of our CCRP. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our provider portal on Availity.
For coding changes, go to Aetna Payer Spaces > Resources. In the search bar, search for “expanded claim edits.”
Except for Student Health, you’ll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to Availity®. You’ll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools.
We may request medical records for certain claims, such as high-dollar claims, implant claims, anesthesia claims, and bundled services claims, to help confirm coding accuracy.
Changes to our National Precertification List (NPL)
These changes apply to our commercial and Medicare members, unless otherwise noted.
Effective January 1, 2026, we’ll require precertification for the following:
• Electrophysiological (EP) study (93654)
• Yondelis® (trabectedin, J9352)
• Docivyx™ (docetaxel, J9172) — Medicare members only
Check out the Original Publication, titles like:
- How to secure an authorization
- Urgent requests
- Changes to commercial drug lists begin on January 1
- And More
2025-2026 Flu Season Pricing
Payment Allowances and Effective Dates for the 2025-2026 Flu Season:
CPT Code or HCPCS code
CPT or HCPCS Short Descriptor
Labeler Name
Vaccine/ Procedure Name
National Payment Allowance
Effective Dates
90653
IIV ADJUVANT VACCINE IM
Seqirus
Fluad Trivalent (2025/2026) Preservative Free
$98.160
08/01/2025-07/31/2026
90656
IIV3 VACC NO PRSV 0.5 ML IM
Seqirus
Afluria Trivalent (2025/2026) Preservative Free
$23.215
08/01/2025-07/31/2026
Sanofi Pasteur
Fluzone Trivalent (2025/2026) Preservative Free
08/01/2025-07/31/2026
GlaxoSmithKline
Fluarix Trivalent (2025/2026) Preservative Free
08/01/2025-07/31/2026
FluLaval Trivalent (2025/2026) Preservative Free
08/01/2025-07/31/2026
90657
IIV3 VACCINE SPLT 0.25 ML IM
Seqirus
Afluria Trivalent (2025/2026)
Pediatric Dose
$11.034
08/01/2025-07/31/2026
Sanofi Pasteur
Fluzone Trivalent (2025/2026)
Pediatric Dose
08/01/2025-07/31/2026
90658
IIV3 VACCINE SPLT 0.5 ML IM
Seqirus
Afluria Trivalent (2025/2026
$22.069
08/01/2025-07/31/2026
Sanofi Pasteur
Fluzone Trivalent (2025/2026)
08/01/2025-07/31/2026
90660
LAIV3 VACCINE INTRANASAL
MedImmune
FluMist Trivalent (2025/2026)
$29.714
08/01/2025-07/31/2026
90661
CCIIV3 VAC ABX FR 0.5 ML IM
Seqirus
Flucelvax Trivalent (2025/2026) Preservative Free
$49.495
08/01/2025-07/31/2026
90662
IIV NO PRSV INCREASED AG IM
Sanofi Pasteur
Fluzone High-Dose Trivalent (2025/2026) Preservative Free
$98.160
08/01/2025-07/31/2026
90673
RIV3 VACCINE NO PRESERV IM
Sanofi Pasteur
Flublok Trivalent (2025/2026)
Preservative Free
$98.160
08/01/2025-07/31/2026
Q2039
INFLUENZA VIRUS VACCINE, NOT OTHERWISE SPECIFIED
N/A
N/A
N/A
08/01/2025-07/31/2026
G0008
ADMIN OF FLU VACCINE
N/A
Administration of influenza virus vaccine
Please see below for
Locality-Adjusted Payment Rates
M0201
FLU VACCINE HOME ADMIN
N/A
Administration of influenza vaccine inside a patient’s home; reported only once per individual home per date of service when such vaccine administration(s) are performed at the patient’s home
Please see below for
Locality-Adjusted Payment Rates
| MAC | State | Locality Number | Locality Name | 2025 GAF (with 1.0 Work Floor | G0008 | G0009 | G0010 | M0201 |
| 04412 | TX | 99 | REST OF TEXAS | 0.972 | $ 32.77 | $ 32.77 | $ 32.77 | $ 38.78 |
How to Search the BCBS Fee Schedule for Quarterly HCPCS (Updated)
Choose “Standards and Requirements”
Then “General Reimbursement Information”
Scroll to the Bottom and enter the password “Manual”, then click submit
Read the Policies Disclaimer or scroll to the bottom and click “Continue”
Then choose “Blue Choice PPO, Blue Essentials, Blue Premier, Blue Advantage HMO, MyBlue Health, Blue High Performance Network Schedules”
Directly under that, select “2024 Schedules effective 2/1/2024”
Scroll down to “CPT/HCPCS Drug Schedule” click
The schedule will open in a PDF. You may search by using “CTRL F”
UHC Network News July 1, 2024
Take Note: Quarterly CPT and HCPCS Code Updates
Effective Jul. 1, 2024, all applicable Medical Policies and Medical Benefit Drug Policies have been updated to reflect the quarterly Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) code additions, revisions, and deletions. Refer to the following sources for information on the code updates:
Aetna March OfficeLink Updates
Changes in Aetna’s Commercial Drug List Begin on July 1, 2024.
Per Aetna, Changes may affect all drug lists, precertification, step therapy and quantity limit programs. Physician offices can view the changes as early as May 1, 2024. The changes can be found on Aetna’s Formularies and Pharmacy Clinical Policy Bulletins page.
Changes in Aetna’s National Precertification List (NPL)
This applies to both Aetna Commercial and Medicare Members. (POET does not have an Aetna Medicare contract at this time.) Per Aetna this change will also be effective July 1, 2024. They will require precertification for:
- Osteotomy posterolateral approach, thoracic
- Osteotomy anterior approach
- Knee meniscectomy-requires precertification for the Medicare Advantage members only.
Per Aetna, Be sure to submit precertification requests at least two weeks in advance. To save time, request precertification on line.
Updated Clinical Prior Authorization
Assistance Chart Now Available
An update to the Clinical Prior Authorization Assistance Chart is available. The chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.
Recent Comments