Administrative bulletin: 2026-10-002 Medicare only

Professional and facility Providers

2027 Medicare Advantage product updates

KEY POINT: Capital Blue Cross has made the following changes and updates to our Medicare Advantage (MA) plans effective January 1, 2027.

Effective January 1, 2027, Capital Blue Cross will no longer reimburse for the following codes for Commercial and Medicare Advantage.

Plan updates and options

Plans exiting certain counties – There are two counties, Northampton and Schuylkill, which will be non-renewed for Capital Blue Cross Enhanced PPO members. There are three counties, Adams, Franklin, and York, that will be non-renewed for Capital Blue Cross Complete PPO members. These members will receive a non-renewal letter by early October and will need to join another MA, Medicare Supplement, or Prescription Drug Plan to continue health coverage beyond December 31, 2026.

Plan expanding county footprint – Capital Blue Cross Basic PPO will expand into the following counties: Columbia, Cumberland, Fulton, Lancaster, Lebanon, Montour, Northumberland, Snyder, and Union. With this change, Capital Blue Cross Basic PPO will now be available in our entire 21-county service area.

Reminder: For 2027, our Capital Blue Cross MA plans’ member cost-sharing (copay, coinsurance, or deductible) may vary depending on the county the member resides in. Please check the member ID card or Availity for the cost-sharing that applies for the service.

Key medical benefit changes

Medical deductible – Continuing for 2027, a medical deductible applies to the Capital Blue Cross Value PPO plan and Basic PPO plan. Deductible amounts may vary depending on the county the member resides in. The deductible does not apply to all in-network benefits. For 2027, inpatient hospital acute, inpatient mental health and skilled nursing facility services are excluded from the in-network deductible.

PCP and specialists – PCP copays are $0 on most plans. Specialist copays have been changed on many of the plans. Please check the member’s ID card or Availity for updated copay amounts.

Diabetic supplies – Reminder, our preferred blood glucose monitor (BGM) and test strips brand for 2027 will continue to be Contour, at 0% coinsurance for in-network services. All other BGMs, including OneTouch, will apply 50% coinsurance for PPO plans, and there will be no coverage outside of Contour for HMO plans. Providers should begin recommending that members switch to Contour if they currently have OneTouch.

Any brand of lancets and BGM solutions will continue to apply a $0 copay when utilizing a network provider. Members should be encouraged to fill diabetic supplies at the pharmacy, which offers the lowest cost.

Lab services – New for 2027, in-network cost sharing will vary by lab service and site of care. Lab services processed by an independent lab, including specimens collected in a provider’s office and sent to an independent lab, will apply a $0 copay. Lab services obtained at or sent to an outpatient facility lab for processing will apply a $20 copay. All genetic testing will apply a $100 copay, regardless of location. When multiple lab services are billed by the same provider on the same claim and date of service, the highest applicable copay will apply. For PPO plans, out-of-network lab services will be subject to 30% coinsurance.

2027 Part D drugs changes

Drug deductible – Most MA plans will have a drug deductible for 2027 that applies to Tiers 3, 4, and 5. Part D insulin and Part D vaccines are excluded from this deductible. Our Tier 1 and Tier 2 preferred pharmacy copays on most MA plans are $0. Members should be encouraged to use Tier 1 or 2 generic drugs, which are excluded from the deductible.

Tier 4 supply limit – All plans will limit the Tier 4 drugs to a 30-day limit. No extended (60 or 100 days) fills will be allowed.

Part D insulin – Reminder, Part D Insulin cost-share is the lesser of $35 copay or up to 25% coinsurance for a 30-day supply.

2027 Medicare Supplemental benefit changes

KEY POINT: The following outlines changes and updates to Capital Blue Cross Medicare Advantage supplemental benefits effective January 1, 2027.

Routine hearing

For all plans, over-the-counter (OTC) hearing aids are no longer covered for 2027. No changes will be made for the routine hearing exam and prescription hearing aid benefit when provided in-network through our vendor.

Out-of-Network (OON) coverage for supplemental benefits

The following supplemental benefits will be covered with 90% member coinsurance for 2027:

• Routine hearing, fitness, OTC, and Virtual Care
  • Members must pay up front and submit a claim for reimbursement. Members can refer to their EOC for additional information.

Annual review and updates to Prime Therapeutics™ guidelines

KEY POINT: Updates have been made to Capital Blue Cross’ clinical guidelines by our vendor, Prime Therapeutics.

Please share these changes with your office staff, as they could impact step therapy authorization requests effective December 1, 2026, for our Medicare Advantage members.

Single source preauthorization list updates – Medicare Advantage

KEY POINT: Updates to the Single Source preauthorization list will occur as described below.

Effective December 1, 2026, the following procedure code(s) will require preauthorization for Medicare Advantage.

Note: Codes that require preauthorization are maintained on the Capital Blue Cross Single source preauthorization list located on Capital’s provider web page.