2023-2024 News and announcements

Stay informed about programs, policies, and announcements issued in 2023-2024 by Blue Shield of California and Blue Shield of California Promise Health Plan.

Recent announcements for Blue Shield Promise providers

View latest announcements

Recent announcements for Blue Shield providers

Specialist and facility support for coordination of care includes promptly sharing consultation and discharge reports with primary care physicians

December 18, 2024 – Effective coordination of health care relies strongly on the prompt sharing of patient information between specialty providers, facility administrators and primary care physicians (PCPs).  Fast access to consultation and facility discharge reports helps patients’ primary care provider (PCP) successfully coordinate care.
Review key reminders (PDF, 100 KB)

Download Blue Shield of California’s updated 2025 Tandem PPO Network participant guide

December 16, 2025 - Beginning January 1, 2025, the Tandem PPO Network will continue to provide in-network services for Tandem PPO plan enrollees and will also be the preferred network for California Employees’ Retirement System (CalPERS) beneficiaries statewide who select the 2025 PERS Gold (PPO) benefit plan.

To assist participating Tandem PPO Network providers, we have updated the Tandem PPO Network Tools & Tips guide, including step-by-step instructions on:

• How to check provider and participating locations that can provide in-network Tandem PPO and PERS Gold plan services: It is important to ensure that the location where you provide services is part of the Tandem PPO Network. There are instances where one location for a solo practitioner, a provider group or provider organization may be part of the Tandem PPO network, while others are not.
• How to check for a Tandem PPO or PERS Gold plan member’s eligibility. The updated guide includes Tandem PPO plan names, as well as referencing the PERS Gold plan.
• How to ensure a Tandem PPO or PERS Gold member claim is processed as an in-network claim: In addition to confirming that the specific location where services are provided is in the Tandem PPO Network, you need to ensure that the service is billed under the correct tax identification number, based on the service location.

We encourage you to download the resources below, and to keep them as a reference for working successfully with Blue Shield for your business needs as you provide services to Tandem PPO and PERS Gold plan members. No login is needed to view or download these resources.
Tandem PPO Network Tools & Tips (PDF, 1.3 MB)
Frequently asked questions (PDF, 84 KB)

Changes to non-ABA behavioral health services UM and care management for PPO self-funded plans, January 1, 2025

December 12, 2024 - Blue Shield of California is implementing changes on January 1, 2025 to help support a long-term strategy for maintaining high-quality behavioral health services while driving cost-effective care utilization and affordability for both plan purchasers and members. The changes will also allow better integration of prior authorizations, claims review, and approaches to behavioral health services.

For most members with benefit plans underwritten as PPO self-funded (“Administrative Services Only,”  “Shared Advantage” or “Shared Advantage Plus”), Blue Shield will assume non-ABA utilization management and care management services currently provided by Magellan Health, Inc. Contact Blue Shield Provider Customer service at (800) 541-6652 for questions about mental health benefit administration regarding a specific member. 

For California Public Employees’ Retirement System (CalPERS) 2025 PPO plan beneficiaries who select CalPERS PERS Platinum or PERS Gold plans, Blue Shield’s administration will include behavioral health utilization management for non-ABA behavioral health provider services and treatment. Included Health, Inc. will administer member customer service and care management for non-ABA behavioral health services for these CalPERS members. 

Blue Shield’s Mental Health Service Administrator, Magellan Health, Inc., will continue to provide utilization management, care management and treatment services for Applied Behavioral Analysis (ABA), for all members with coverage under the benefit plan types described below. The FAX and phone numbers for reaching Magellan Health, Inc. remain the same.
Read details in frequently asked questions (PDF, 144 KB)

Virtual PCP and IPA/medical group option for Trio HMO members expands to 28 counties on January 1, 2025

December 4, 2024 - Blue Shield of California is pleased to announce the expansion of the virtual primary care physician and medical group assignment option for Trio HMO plan members within select ZIP code areas of 28 California counties, effective January 1, 2025. Trio HMO members who reside in the designated service areas and who select or are assigned to PlushCare of California, P.C, dba Accolade Care can conveniently access preventive and primary care with a virtual PCP and provider group. When appropriate, Accolade Care will also coordinate virtual specialist care for those members through Telemedicine Group P.C., dba TeleMed2U, Inc.
Register for the January 15, 2025 webinar
Download the Provider Guide (PDF, 1.4 MB)
Read frequently asked questions (PDF, 139 KB)

DispatchHealth Services are Available to Eligible Blue Shield of California Members

November 25, 2024 - We are pleased to announce that DispatachHealth® is available to eligible Blue Shield of California commercial HMO and PPO plan members with serious health concerns to provide same-day, high acuity medical care in the comfort of their home, reducing unnecessary ambulance trips and costly visits to the emergency room. In addition, DispatchHealth provides proactive post-acute visits for members transitioning from hospital to home, also known as “bridge care.”
Download a DispatchHealth flyer to learn more (PDF, 823 KB)
Read frequently asked questions (PDF, 632 KB)

Free online training available to Blue Shield of California network providers on ways to enhance patient experience and practice management

November 25, 2024 – Blue Shield of California is pleased to provide access to training opportunities at no cost to network providers, presented by Press Ganey on behalf of Blue Shield. The webinar training covers such topics as improving access without adding staff, five steps to closing equity gaps, making an impact without adding time, and more topics aimed at maximizing a positive patient experience in addition to business efficiency. We encourage network providers to take advantage of this training, and we will be posting a monthly schedule of available training courses.
View and download December 2024 schedule (PDF, 126 KB)

New resources available regarding medical claims billing for professional services provided by pharmacists

November 18, 2024 – As part of California Assembly Bill 317 (AB 317) Blue Shield of California accepts medical claims for pharmacist professional services that are eligible for reimbursement. Blue Shield has recently developed and released resources to assist pharmacists in billing for professional services.
Download a quick reference guide for more information (PDF, 1.7 MB)

Reminder of behavioral health timely access to care standards and after-hours emergency instructions

November 14, 2024 – Blue Shield of California is providing a reminder to behavioral health care providers about the importance of following timely access to care standards and having appropriate after-hours emergency instructions available to Blue Shield HMO and PPO plan members. By adhering to established standards, your practice can help ensure access to care and contribute to improved behavioral health outcomes for Blue Shield members.
Review access to care standards and acceptable after-hours emergency instructions (PDF, 213 KB)

Certain behavioral health specialty medications for Blue Shield of California commercial HMO plan members available to order directly from participating specialty pharmacies

November 11, 2024 - Blue Shield of California allows behavioral health specialty medications to be ordered directly from a specialty pharmacy for HMO commercial plan members. Blue Shield is financially responsible for the medications listed in the Q4 Behavioral Health Specialty Medications list available on the Medication Claims, Policies and Guidelines page on our Provider Connection Website, regardless of whether the IPA/medical group has a full or shared risk agreement with Blue Shield.
Read frequently asked questions (PDF, 187 KB)

Free online training available to Blue Shield of California network providers on ways to enhance patient experience and practice management

November 1, 2024 – Blue Shield of California is please to announce free training opportunities presented by Press Ganey on behalf of Blue Shield. The webinar training covers such topics as improving access without adding staff, five steps to closing equity gaps, making an impact without adding time, and more topics aimed at maximizing a positive patient experience in addition to business efficiency. We encourage network providers to take advantage of this training, and we will be posting a montly schedule of available training courses.
View and download November 2024 schedule (PDF, 100 KB)

Amazon Pharmacy Becomes Blue Shield’s Prescription Home Delivery Service Provider for Non-Specialty Drugs Beginning January 1, 2025 

November 1, 2024 – Beginning January 1, 2025, Amazon Pharmacy will be the prescription home delivery service provider for members who have prescription benefits through Blue Shield of California. This means that as of January 1, 2025, CVS Caremark® Mail Service Pharmacy will no longer be filling non-specialty prescriptions for Blue Shield members. Non-controlled prescriptions with available refills will automatically be transferred to Amazon Pharmacy on January 1, 2025. After December 31, 2024, you will need to send new prescriptions directly to Amazon Pharmacy if your patient wants to continue to use home delivery. Amazon Pharmacy does not fill prescriptions for Schedule II controlled substances or compounded or reconstituted medication. Those prescriptions will need to be filled by the member at a retail pharmacy. New prescriptions for any Schedule III – V controlled substances, however, may be sent by providers directly to Amazon Pharmacy.
Find more information at https://pharmacy.amazon.com/prescribers.

Change to weight loss medication coverage for some Blue Shield of California commercial plan members beginning January 1, 2025

November 1, 2024 - Beginning January 1, 2025, or upon the employer group’s or individual purchaser’s plan renewal after that date, certain weight loss medications will no longer be covered for some Blue Shield of California (Blue Shield) commercial PPO and HMO plan members unless authorization for medical necessity is provided by Blue Shield. Blue Shield will authorize weight loss medications for members affected by the benefit change if the medication is medically necessary for the treatment of a current or previous diagnosis of Class III (morbid) obesity. Please be certain to verify patient eligibility and authorization requirements before prescribing weight loss medications on and after January 1, 2025..
Review the affected medication list and more (PDF, 72 KB)

New Humira Biosimilar Available Beginning January 1, 2025

October 31, 2024 – Effective January 1, 2025, Blue Shield of California is adding a Humira biosimilar, adalimumab-aacf, to the Blue Shield commercial plan formularies, and removing Humira and Hadlima.
Read frequently asked questions (PDF, 443 KB)

Adhering to requirements for hospital admission notifications helps facilities avoid adverse determinations

October 23, 2024 - Blue Shield of California’s Utilization Management team has sent notifications reminding network hospitals that observation status for a visiting Blue Shield health plan member does not require medical necessity review nor authorization. If an observation stay needs to be converted to an inpatient stay, hospitals should adhere to the policy available in Blue Shield’s Hospital and Facility Guidelines Manual, Section 3. Sending the supporting clinical records in a timely manner aligns with industry standards and efficiently supports Blue Shield’s concurrent review processes.
Review requirements in our provider manual (PDF, 244 KB)

Change to Requirements for IPA Authorization Log Submissions, beginning January 1, 2025

October 11, 2024 - Beginning January 1, 2025, All Blue Shield of California network IPA/medical groups will be required to submit authorization logs for medical and/or pharmacy medical benefit services processed for members using the authorization log submission capability on our Provider Connection website. This Provider Connection authorization submission process is for IPAs that are currently sending authorization logs via email or who use secure file transfer protocol (SFTP) to send authorization logs in the IPA9 format. Starting January 1, 2025, Blue Shield will no longer accept authorization log email or IPA9 SFTP submissions. If you already send your logs via IPA10 SFTP, this is not applicable.
Review the IPA authorization log tutorial for more information   (PDF, 476 KB)

2024 Provider Cultural Awareness and Linguistics Resources and Training Available

October 7, 2024 - Blue Shield of California has developed cultural awareness and linguistics reference materials to assist network providers in giving the highest level of quality care and services to our health plan members. These resources include links to a free online cultural competency in care training with continuing education unit (CEU) credits, demographics and language services information, translation services, and translated materials.
Read about resources  (PDF, 121 KB)

New Virtual PCP and medical group option for Trio HMO members in select areas

September 26, 2024 - Blue Shield of California is pleased to announce a new virtual primary care physician (PCP) and medical group option for Trio HMO members in select areas within Riverside, Santa Barbara, San Bernadino, San Luis Obispo, and Ventura counties. By selecting or being assigned to PlushCare of California, P.C, dba Accolade Care, Trio HMO members can conveniently access preventive and primary care through a virtual provider group within Blue Shield’s Trio HMO Network. These members will be referred to other Trio HMO Network participating groups or practitioners for in-person care when it is determined to be medically necessary.
Register now to learn more at our October 16, 2024 webinar
Read frequently asked questions  (PDF, 83 KB)

Medication Policy and Formulary Updates 3rd Quarter 2024

August 1, 2024 - View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary  (PDF, 178 KB)

ASPN Pharmacies reduces administrative burden via Drop Ship Medication Program

August 22, 2024 – Since May 1, 2024, specialty medications available to eligible Blue Shield PPO commercial plan members through our Drop Ship Medication Program are now managed by ASPN Pharmacies (ASPN) on behalf of Blue Shield. ASPN triages your order, coordinates prescription fulfillment with specialty pharmacies in the Blue Shield network for direct shipment to your office, then bills Blue Shield directly.
Read details about ASPN’s role in our Medication Drop Ship Program (PDF, 475 KB)

Concierge Services Expanded for Site of Service Program beginning August 1, 2024

July 31, 2024 - We are pleased to announce that beginning August 1, 2024, concierge services for our Site of Service Program, in collaboration with ASPN Pharmacies, will now be available for all medications listed in our current Site of Service Program drug list. This expansion follows a three-month pilot that included five medication categories. 
Read frequently asked questions (PDF, 63 KB)
 

Complex Care Management Programs available to eligible plan members in select geographical areas

July 31, 2024 - Blue Shield of California and Blue Shield of California Promise Health Plan offer eligible members with multiple, select chronic illnesses special programs to help them manage their complex care needs as effectively as possible. 

ConcertoCare complex care services are available to eligible Blue Shield HMO or PPO commercial plan members, Blue Shield Medicare Advantage HMO or PPO plan members, and Blue Shield Promise Medi-Cal plan members, in select geographical areas.

Altais and BT Health are available to provide complex care management services to eligible Blue Shield HMO and PPO commercial plan members and Blue Shield Medicare Advantage HMO and PPO plan members, in select geographical areas.
Learn more
 

GLP-1 medication shortage

June 29, 2024 – Demand and supply challenges have contributed to a global shortage of GLP-1 medications, such as Mounjaro and Trulicity that are used to treat type 2 diabetes. Patients may not be able to access GLP-1 prescribed medications as retail and mail service pharmacies are reporting to have no inventory and/or limited supply of GLP-1 medications due to the shortage. Alternative medication choices may be needed.

Blue Shield of California is encouraging prescribers to talk to Blue Shield members about alternatives that they may be able to take in addition to or in place of their GLP-1 drug to help manage their diabetes.
 

SB 805 expands definition of QASP to include additional professionals

June 29, 2024 – Effective January 1, 2024, California Senate Bill 805 (SB 805) expanded the definition of qualified autism service professionals (QASP) to include psychological associates, associate marriage and family therapists, associate clinical social workers, and associate professional clinical counselors. The bill also requires that those who qualify as a QASP meet the training and experience criteria established by the California Department of Developmental Services by July 1, 2026. 

In accordance with the law, Blue Shield of California encourages all participating network providers to comply with the changes made via SB 805 to Health & Safety Code Section 1374.73 and Insurance Code Section 10144.51.
 

Medication Policy and Formulary Updates 2nd Quarter 2024

May 2, 2024 - View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary  (PDF, 1.5 MB)
 

LOINC codes needed for reporting depression screenings

April 22, 2024 – To meet HEQMS and HEDIS® standards, providers need to document depression screenings using LOINC® codes (Logical Observation Identifiers Names and Codes). While LOINC codes are not required for claims payment, not meeting these standards may negatively impact quality incentive payouts.
Read about depression screenings and LOINC codes (PDF, 487 KB)
 

Medication Policy and Formulary Updates 1st Quarter 2024

February 1, 2024 - View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary  (PDF, 1.1 MB)
 

Preferred Specialty Drug List for Medical Benefits Updated on January 1, 2024

December 31, 2023 – View a summary of the updated Preferred Specialty Drug List for medical benefits, effective January 1, 2024.
View list (PDF, 60 KB)
 

Specialists and facilities: Please share reports promptly with PCPs

December 1, 2023 – All specialty providers and facility administrators should promptly deliver consultation reports and facility discharge reports to their patients’ primary care provider (PCP) to support coordination of care.
Review notice (PDF, 93 KB)
 

New online dispute functionality

November 17, 2023 – You can now file disputes online for Blue Shield Medicare and Blue Shield Promise Medi-Cal claims. We’ve also revised the process for submitting bulk disputes. We now ask you to organize bulk dispute submissions by plan type – such as commercial, Medicare, or Medi-Cal.
See what's new
 

Medication policy and formulary updates 4th quarter 2023

November 2, 2023 – View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary (PDF, 1.2 MB)
 

ASPN Pharmacies triage services available for home infusion, beginning October 1, 2023

October 12, 2023 – Blue Shield of California has teamed up with ASPN Pharmacies (ASPN) to offer enhanced services and simpler processes for eligible HMO and PPO commercial plan members to arrange for home infusion services. Providers may now place orders with ASPN and they will work directly with members to find access to local home infusion providers.
Read frequently asked questions (PDF, 157 KB)
 

Cultural awareness and linguistics resources available

October 6, 2023 – Blue Shield has developed cultural awareness and linguistics reference materials to help our providers give the highest level of quality care and services to our shared members. These resources include free cultural competency training with CEU credits, demographics and language services information, translation services, and translated materials.
Access resources (PDF, 881 KB)
 

Provider Directory enhancement: Indicate that a provider offers gender affirming care

September 19, 2023 – We have recently updated the Blue Shield of California provider directory to enable you to indicate if a provider or organization offers gender affirming care services. This will allow members to use the Find a Doctor tool to connect with providers who offer these services. Please note that this identification should only be used for providers of specific gender affirming care services.
Read about the enhancement (PDF, 195 KB)
 

COVID 19 benefits policy

September 12, 2023 – Blue Shield of California has published a benefits policy regarding COVID-19 testing, therapeutics and related services, effective September 27, 2023, in accordance with California Health and Safety Code sections 1342.2 and 1342.3.
Review this COVID-19 benefit policy (PDF, 1.2 MB)
 

Medication policy and formulary updates 3rd quarter 2023

August 3, 2023 – View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary (PDF, 1.2 MB)
 

New forms available for radiation oncology prior authorization and post-service requests

June 30, 2023 – To help simplify the process of requesting authorization for radiation oncology services, Blue Shield of California has created two forms that may be faxed to us. One form may be used to request prior authorization and the other form may be used for post-service claims. Please note that use of these forms is NOT mandatory. We provide them to make it easier for you to submit requests and to help make sure that we receive all the information and documentation that is required to process claims.
See how to access the forms (PDF, 180 KB)
 

Medication policy and formulary updates 2nd quarter 2023

May 4, 2023 – View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary (PDF, 1.4 MB)
 

Preferred Specialty drug list for Medical Benefits updated on March 1, 2023

April 10, 2023 – View a summary of the updated Preferred Specialty Drug List for medical benefits, effective March 1, 2023.
View list (PDF, 29 KB)
 

How Senate Bill 1419 affects access to patient records and the sharing of test results

April 7, 2023 – Read a summary of California Senate Bill 1419 requirements for managing access to patient records and sharing test results. While some items in the bill are already part of existing privacy mandates, others may require changes to your current practices.
Read the summary (PDF, 248 KB)
 

ASPN Pharmacies added to Blue Shield of California’s Drop Ship Program, April 1, 2023

April 4, 2023 – We are pleased to announce that on April 1, 2023, ASPN Pharmacies joined the Blue Shield of California Drop Ship Program. ASPN Pharmacies improves the provider experience in drug procurement by triaging and coordinating prescription fulfillment, with status updates available through the ASPN web portal.
Read frequently asked questions (PDF, 83 KB)
 

Genetics Medical Policy updates

March 9, 2023 – Blue Shield of California recently notified providers that we are working to clarify and simplify coverage of genetic tests. In the coming months we will be reorganizing, updating, and reformatting our genetic testing medical policies and making those policies easier to locate. We will continue to post updated versions of these policies throughout 2023. You can review genetic testing medical policies on our Provider Connection website www.blueshieldca.com/provider.
Review notice (PDF, 44 KB)
 

Home Infusion benefit change lowers cost for eligible medication infusion therapy services for Blue Shield commercial PPO plan members

February 10, 2023 – Blue Shield of California is supporting its mission to lower the cost of health care for members by improving home infusion benefits for commercial PPO plan members. Members with prescriptions for medication infusion therapy services in an outpatient hospital setting can receive their infusion at their home from a network home infusion provider at a $45 copay.
Read frequently asked questions (PDF, 82 KB)
 

Medication policy and formulary updates 1st quarter 2023

February 2, 2023 – View a summary of Pharmacy and Therapeutics Committee decisions on injectable medication policy updates and formulary changes.
View summary (PDF, 926 KB)