Blue KC to Extend Prior Authorization Approval Timeframes on Select Drugs

Beginning June 2025, Blue KC is allowing extended prior authorization approval timeframes on the following pharmacy and medical benefit drugs:

Praluent	Repatha	Juxtapid	Nexletol	Nexlizet	Ofev	Uptravi	Tracleer
Tadliq	Opsumit	Orenitram	Tyvaso	Adempas	Ventavis	Opsynvi	Winrevair
Kalydeco	Trikafta	Symdeko	Orkambi	Pulmozyme	Alyftrek	Plegridy	Lemtrada
Rebif	Ponvory	Extavia	Kesimpta	Mayzent	Betaseron	Bafiertam	Avonex
Vumerity	Zeposia (MS dx only)	Tascenso ODT	Briumvi	Ocrevus	Tysabri	Leqvio

This allows members with chronic conditions, such as multiple sclerosis or cystic fibrosis along with others, to continue medications without interruption if therapy remains consistent. The new authorization will remain valid if the following criteria continue to be met:

• The member remains compliant with therapy at the dosage and frequency originally approved.
• The member continues to demonstrate a positive clinical response to the drug.
• The member remains under the care of a healthcare provider who oversees the ongoing monitoring of the medication.
• The authorized medication continues to be covered by the Member’s plan benefits.
  • For medications covered under the pharmacy benefit, the medication is listed in the Plan formulary (unless an exception has been made by Blue KC).
  • If a brand drug becomes available as a generic and the brand name is no longer preferred or on formulary, the authorization will be termed.

If a patient experiences a change in therapy, the usual prior authorization process will apply. Any changes to dosage or dosing frequency will necessitate a new prior authorization.

Blue KC Speeds up Prior Authorization Process on Provider Portal

How would you like to have your prior authorization automatically approved in a matter of minutes?

It’s now possible to obtain many of our prior authorizations in just minutes with a new automated, evidence-based system to facilitate the process. Here’s how the process works:

• Submit an electronic prior authorization request on the Blue KC Provider Portal at Providers.BlueKC.com.
• Once you log in and arrive on the home page, click on “Prior Authorization.”
• Select the appropriate guideline and document the patient’s clinical indications to support the request.
• Blue KC will automatically notify you of the authorization determination.

You may be asked to submit medical records if more information is needed after the prior authorization is submitted. We encourage you to speak with your Provider Account Executive or call the Blue KC Provider Hotline at 816-395-3929 to learn more about this faster prior authorization process or offer feedback on the process.

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Payment Policy Updates

The most up-to-date Payment Policies can be found by logging into Providers.BlueKC.com and clicking on “Go to Payment Policies”, where there are sections for All Provider Payment and Coding Policies and Lab Payment Policies.

POL-PP-257 Inpatient-only Procedures Payment Policy

Beginning September 1, 2025, Blue KC will implement the CMS Inpatient-only list. The Inpatient-only list consists of surgeries/procedures that will only be paid as an Inpatient procedure in an acute hospital setting.

• This policy applies to all physicians and facilities, unless the provider’s Blue KC network participation agreement contains a specific rate of reimbursement for the Inpatient-only procedure code performed outside of an acute hospital setting.
• If a surgery/procedure on the Inpatient-only list is performed as outpatient and reported on an outpatient claim, no payment will be made to the facility for the surgery/procedure or for any other services provided on the same date of service.
• The Inpatient-only surgery/procedure list is available at the site below:
  • https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations-and-notices-items/cms051449
• *To read the full policy for POL-PP-257 Inpatient-only Procedures Payment Policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

POL-PP-102 Anesthesia Processing Payment Policy

The following updates were added to Anesthesia Processing Payment Policy POL-PP-102, effective July 1, 2025:

• Multiple Anesthesia Services, Same patient, Same day
  • When a patient undergoes multiple surgical procedures on the same day, anesthesia is billed based on the procedure with the highest base unit value. The total anesthesia time is the combined time for all procedures performed that day, not a separate charge for each procedure.
    
    Blue KC follows the National Correct Coding Initiative, as outlined in Payment Policy POL-PP-226 National Correct Coding Initiative (NCCI). Coding conflicts for anesthesia were added to the policy for provider education.
• Standard Preparation/Monitoring Services for Anesthesia
  • Regardless of the mode of anesthesia, preparation and monitoring services are not separately reportable with anesthesia service HCPCS/CPT codes when performed in association with the anesthesia service. However, if the provider/supplier of the anesthesia service performs 1 or more of these services prior to and unrelated to the anticipated anesthesia service or after the patient is released from the anesthesia practitioner’s postoperative care, the service may be separately reportable with modifiers 59 or XE or XU.
• Anesthesia Service Included in the Surgical Procedure
  
  Separate payment for anesthesia services performed by the physician who also furnishes the medical or surgical service is not allowed. In this case, payment for the anesthesia service is included in the payment for the medical or surgical procedure. For example, separate payment is not allowed for the physician’s performance of local, regional or most other anesthesia including nerve blocks if the physician also performs the medical or surgical procedure. Generally, separate reporting for moderate conscious sedation services (CPT codes 99151-99153) when provided by the same physician performing a medical or surgical procedure is allowed.
• *To read the full policy for POL-PP-102 Anesthesia Processing Payment Policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Telehealth Payment Policy POL-PP-109

The following updates were added to Telehealth Payment Policy POL-PP-109:

Effective September 1, 2025, revenue code 0780, Telehealth general classification, is used to bill for facility fees associated with the telehealth originating site. This code is considered mutually exclusive to other telehealth services and is not separately reimbursable.

On January 1, 2025, the American Medical Association created 16 new codes for telehealth to replace office visit codes 99202-99215. The description of these codes is broken down into new and established patient, synchronous audio-video and synchronous audio-only visits.

Blue KC previously communicated that we would no longer allow office codes 99212-99215 for telehealth visits, and providers were to use the new telehealth codes 98000-98015. Due to few payers adopting these new codes and the burden it may cause for offices doing secondary billing, Blue KC will now allow providers to use either codes 99202-99215 or telehealth visit codes 98000-98015 with place of service 02 or 10.

*To read the full policy for Telehealth Services Payment Policy POL-PP-109, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Prolonged Service and Visit Complexity Payment Policy POL-PP-129

Effective September 1, 2025, Blue KC wants to inform you that a new CPT code for 2025 in Prolonged Service and Visit Complexity Payment Policy POL-PP-129 is G0545 (visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious disease specialist).

G0545 is an add-on code and is submitted in addition to a hospital inpatient or observation evaluation and management visit. Blue KC will not separately reimburse HCPCS code G0545 and considers payment to be included by the payment for services to which it is incident to.

*To read the full policy for Prolonged Service and Visit Complexity Payment Policy POL-PP-129, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Durable Medical Equipment Payment Policy POL-PP-195

The following details were added to Durable Medical Equipment Payment Policy POL-PP-195 to provide clarification (guidelines are the same) on Durable Medical Equipment (DME) with no Medically Unlikely Edits (MUE) and submissions of 90-day payment for certain medical supplies:

When NCCI has no MUE for a code, Blue KC will decide on an appropriate MUE limit based on HCPCS/CPT code descriptors, CPT coding instructions, anatomic considerations, established CMS policies, nature of service or procedure, nature of analyte, nature of equipment, prescribing information and clinical judgment.

As a reminder, when submitting a claim for a 90-day supply, Blue KC is asking DME providers to submit each month on a separate line to ensure accurate and prompt payment.

*To read the full policy for Durable Medical Equipment Payment Policy POL-PP-195, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Lab Payment Policies, effective July 1, 2025

Blue KC wants to inform you that we have updated the effective date to July 1, 2025, for the Lab Payment Policies listed below. These policies are in collaboration with our vendor partner, Avalon, to ensure correct coding of laboratory services.

The following Lab Payment Policies will be applied to lab services (80047 – 89398):

Allergen Testing POL-PP-259	β Hemolytic Streptococcus Testing POL-PP-260	Biochemical Markers of Alzheimer Disease and Dementia POL-PP-261	Biomarker Testing for Autoimmune Rheumatic Disease POL-PP-262
Biomarkers for Myocardial Infarction and Chronic Heart Failure POL-PP-263	Bone Turnover Markers Testing POL-PP-264	Cardiovascular Disease Risk Assessment POL-PP-265	Celiac Disease Testing POL-PP-266
Cervical Cancer Screening POL-PP-267	Colorectal Cancer Screening POL-PP-268	Coronavirus Testing in the Outpatient Setting POL-PP-269	Diabetes Mellitus Testing POL-PP-270
Diagnosis of Idiopathic Environmental Intolerance POL-PP-271	Diagnosis of Vaginitis POL-PP-272	Diagnostic Testing of Common Sexually Transmitted Infections POL-PP-273	Diagnostic Testing of Influenza POL-PP-274
Diagnostic Testing of Iron Homeostasis & Metabolism POL-PP-275	Epithelial Cell Cytology in Breast Cancer Risk Assessment POL-PP-276	Evaluation of Dry Eyes POL-PP-277	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing POL-PP-278
Fecal Calprotectin Testing in Adults POL-PP-279	Flow Cytometry POL-PP-280	Folate Testing POL-PP-281	Gamma-Glutamyl Transferase Testing In Adults POL-PP-282
General Inflammation Testing POL-PP-283	Helicobacter Pylori Testing POL-PP-284	Hepatitis Testing POL-PP-285	Human Immunodeficiency Virus (HIV) POL-PP-286
Identification of Microorganisms using Nucleic Acid Probes POL-PP-287	Immune Cell Function Assay POL-PP-288	Immunohistochemistry POL-PP-289	Immunopharmacologic Monitoring of Therapeutic Serum Antibodies POL-PP-290
In Vitro Chemoresistance and Chemosensitivity Assays POL-PP-291	Intracellular Micronutrient Analysis POL-PP-292	Lyme Disease Testing POL-PP-293	Metabolite Markers of Thiopurines Testing POL-PP-294
Nerve Fiber Density Testing POL-PP-295	Onychomycosis Testing POL-PP-296	Oral Cancer Screening and Testing POL-PP-297	Pancreatic Enzyme Testing for Acute Pancreatitis POL-PP-298
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing> POL-PP-299	Pathogen Panel Testing POL-PP-300	Pediatric Preventive Screening POL-PP-301	Prenatal Screening (Nongenetic) POL-PP-302
Prescription Medication and Illicit Drug Testing in the Outpatient Setting POL-PP-303	Prostate Biopsy Specimen Analysis POL-PP-304	Prostate Specific Antigen (PSA) Testing POL-PP-305	Salivary Hormone Testing POL-PP-306
Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases POL-PP-307	Serum Testing for Evidence of Mild Traumatic Brain Injury POL-PP-308	Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease POL-PP-309	Serum Tumor Markers for Malignancies POL-PP-310
Testing for Autism Spectrum Disorder and Developmental Delay POL-PP-311	Testing for Diagnosis of Active or Latent Tuberculosis POL-PP-312	Testing for Vector-Borne Infections POL-PP-313	Testosterone POL-PP-314
Therapeutic Drug Monitoring for 5-Fluorouracil POL-PP-315	Thyroid Testing POL-PP-316	Urinary Tumor Markers for Bladder Cancer POL-PP-317	Urine Culture Testing for Bacteria POL-PP-318
Vitamin B12 and Methylmalonic Acid Testing POL-PP-319	Vitamin D Testing POL-PP-320

*To read the full versions of the Lab Payment Policies, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services Payment Policy POL-PP-233

As we announced in our April Provider Bulletin, Blue KC wants to remind you that the updates outlined below to Hemodialysis Services Payment Policy POL-PP-233 will become effective on July 1, 2025. The payment policy will also be renamed Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services Payment Policy POL-PP-233 on July 1, 2025.

• This payment policy will be updated to include hemodialysis and peritoneal dialysis performed in the home.
• This update will include documentation requirements, self-dialysis training guidelines and correct coding for facility and home dialysis.

Dialysis Treatment	Revenue Code	CPT code
Hemodialysis Professional billing	0821	90935, 90937
Hemodialysis Facility billing	0821	90999
Peritoneal dialysis Professional billing	0841 or 0851	90945, 90947
Peritoneal dialysis Facility billing	0841 or 0851	90999
Hemodialysis (home)	0821	S9335
Peritoneal (home)	0840 or 0851	S9339
Self-Dialysis Training Complete	0849 or 0859	90989
Self- Dialysis Training Incomplete	0849 or 0859	90993

• Blue KC will not reimburse CPT 90999 Unlisted dialysis procedure, inpatient or outpatient for home dialysis.
• Facilities should submit S9335 for home hemodialysis and S9339 for home peritoneal dialysis.
• Self-dialysis training is reimbursed for dialysis units and/or centers that train dialysis patients to self-dialyze at home or in a self-dialysis unit at a facility. This applies to all dialysis modalities where training is furnished and is mandatory for at home therapy. Home therapy charges submitted without training will be denied.

*To read the full policy for Hemodialysis Services Payment Policy POL-PP-233, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Facility Observation G0378, G0379 Payment Policy POL-PP-258

As we announced in our April Provider Bulletin, the new Facility Observation G0378, G0379 Payment Policy POL-PP-258 will be effective on August 1, 2025. Here are more details:

• Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment, which are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
• Observation services must be reported by facilities utilizing the following guidelines:
  • Observation services are submitted with bill type 13X, 78X, or 85X.
  • Report HCPCS code G0378 (hospital observation service, per hour) under the appropriate revenue code (0762) with units that represent the hours in observation care (rounded to the nearest hour).
  • Observation service code G0378 will only be considered for reimbursement when the observation period meets or exceeds 8 hours, but not more than 48 hours.
• Observation services code G0378 should only be reported when one of the following services was also provided on the same date of service or the day before the date reported for observation:
  • Emergency Department visit (99281-99285, G0380-G0384), or
  • Clinic visit (HCPCS code G0463), or
  • Critical care (CPT code 99291), or
  • Direct referral for observation care reported with HCPCS code G0379 which must be reported on the same date of service as the date reported for observation
• Observation services must be reported on a single line and the date of service for that line is the date that observation care begins.
  • Observation services should not be reported with a date span or on separate claim lines even when the period of observation care spans more than one calendar day.
• Observation care should not be reported for monitoring that is inclusive of, or included in payment for, a surgical, diagnostic, or therapeutic procedure.

*To read the full policy for Facility Observation G0378, G0379 Payment Policy POL-PP-258, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Robotic and Computer Assisted Surgery Payment Policy POL-PP-232

The following updates to Robotic and Computer Assisted Surgery Payment Policy POL-PP-232 will become effective on August 1, 2025.

• The use of robotics/computer assisted surgery may be considered an alternative to the corresponding standard surgical procedure if it employs the same surgical techniques and principles as standard surgery.
• Reimbursement will be based on the standard code for the procedure (e.g., the laparoscopic prostatectomy, stereotactic radiosurgery).
  
  Blue KC considers robotic assist (S2900) and computer assist (0054T, 0055T, 20985) a component of (subset to) the primary procedure, and no additional reimbursement will be made.

*To read the full policy for the Robotic and Computer Assisted Surgery Payment Policy POL-PP-232, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

SBRT, SRS, FSRT Payment Policy POL-PP-250

As we announced in our April Provider Bulletin, the following updates to SBRT, SRS, FSRT Payment Policy POL-PP-250 will become effective on July 1, 2025.

• Payment for services identified by the CPT codes listed below are included in payment for CPT code 77301, which stands for Intensity modulated radiotherapy plan (IMRP), including dose-volume histograms for target and critical structure partial tolerance specifications). These codes should not be reported in addition to CPT 77301 when provided prior to or as part of the development of the IMPRT plan.
  • 77014 – Computed tomography guidance for placement of radiation therapy fields
  • 77280 – Therapeutic radiology simulation-aided field setting; simple
  • 77285 – Therapeutic radiology simulation-aided field setting; intermediate
  • 77290 – Therapeutic radiology simulation-aided field setting; complex
  • 77306 – Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)
  • 77307 – Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)
  • 77321 – Special teletherapy port plan, particles, hemibody, total body
  • 77331 – Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
  • *To read the full policy for SBRT, SRS, FSRT Payment Policy POL-PP-250, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Enforcement of Modifiers for the Gap Fill Fee Schedule

Effective October 1, 2025, Blue KC Modifiers Payment Policy POL-PP-108 will be enforced for codes on the Gap Fill Fee Schedule. This update will apply to providers who have rebased contracts that are based on CMS methodology and will allow for better consistency with the Blue KC Modifiers Payment Policy.

To see how a modifier will affect a code in the Gap Fill Fee Schedule, please reference the Blue KC Modifiers Payment Policy by going to the log-in page at Providers.BlueKC.com and clicking on Go to Payment Policies. To find the current Blue KC Gap Fill fee schedule, log into Providers.BlueKC.com, click on Resources on the home page and select the Gap Fill Fee Schedule tab. The rates posted on the fee schedule are the base rates (without payment modifier adjustments).

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Medical Policy Updates

The most up-to-date Medical Policy can be found by logging into Providers.BlueKC.com and clicking on the Medical Policies section. While on that web page, you can also find a link to view Milliman Care Guidelines (MCG), which complement our Blue KC policies.

The Blue KC Medical Policy encompasses internal Blue KC Medical Policy, Blue Cross Blue Shield Association derived Medical Policy and policies adopted from our vendor partners, such as Avalon, MCG and eviCore. A few of the updates are listed below:

Evicore Updates

Effective date – 7/1/2025

CMM-200Epidural Steroid Injections CMM-201Facet Joint Injections/Medial Branch Blocks CMM-203Sacroilliac Joint Procedures CMM-204Prolotherapy CMM-207Epidural Adheslolysis CMM-208Ablations/Denervations of Facet Joints and Peripheral Nerves CMM-209Regional Sympathetic Blocks CMM-210Implantable Intrathecal Drug Delivery Systems CMM-211Spinal Cord Dorsal Root Ganglion Stimulation CMM-308Intradiscal Procedures CMM-400Anesthesia Services for Intraventional Pain Procedures Preface to the Comprehensive Musculoskeletal Guidelines

Interim Update

Effective date – 7/1/2025

ID: 1.01.30 Title: Automated Insulin Delivery Systems (Formally Artificial Pancreas Device Systems) Policy title changed to Automated Insulin Delivery Systems. Policy updated with new evidence following FDA approval of the t:slim X2 insulin pump with Control-IQ+ technology for adults with type 2 diabetes. Medically necessary policy statement with criteria revised in individuals with type 2 diabetes.

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Pharmacy Policy Updates

Blue KC Helps Members Save Money with CivicaScript’s generic prostate cancer drug

Generic drugs have had a profound impact on lowering the overall cost of prescriptions. However, in recent years, the prices of some generics have risen substantially.

CivicaScript®1 has proven its ability to change that with its first product, abiraterone acetate, a generic treatment for prostate cancer. It’s offered through a partnership with Blue Cross and Blue Shield of Kansas City (Blue KC) and 22 other Blue Cross and Blue Shield (BCBS) companies.

A study published in May 2025 by the New England Journal of Medicine Catalyst examined the savings achieved by BCBS members who used CivicaScript’s first generic drug:

• Members who access abiraterone acetate through CivicaScript paid $45 per month
• Members who access abiraterone acetate from other manufacturers pay $126 a month
• CivicaScript directly saved members 64% — nearly $1,000 per year per member2

Just as BCBS members have experienced the cost benefits of CivicaScript’s abiraterone acetate, closer to home, so have Blue KC employer groups, which have realized cost savings per claim averaging over 95%3 per group.

Danny Weiss, VP, Chief Pharmacy Officer, Blue KC, explains that these plan costs have a secondary benefit to members because reducing claims costs helps to reduce premiums for our members. We have seen this benefit directly over the two years that our plan has partnered with this lower cost option.

CivicaScript works to develop and manufacture generic alternatives for drugs that have too little competition and too high a price. It focuses on transparency and collaboration throughout the value chain – from manufacturing through dispensing – and passes the cost savings along to patients. CivicaScript expects to launch additional products by fall 2025.

¹CivicaScript is the Civica, Inc. operating unit that is bringing unprecedented transparency to the drug supply chain to make quality generic medicines affordable and available for everyone. The nonprofit company is committed to the principles of providing affordable, essential generic medicines to promote the social welfare and health of the community. CivicaScript’s members represent more than 100 million covered lives in the United States.

² New England Journal of Medicine Catalyst, Changing the Script on Drug Pricing: A New Type of Supplier Creates Savings for Patients and Plans, May 2025

³ Based on Blue KC claims experience from the January 1, 2022, launch of the CivicaScript program to June April 30, 2025.

New Pharmacy Policy

Here is a new Blue KC pharmacy policy for a drug that will require prior authorization effective September 1, 2025:

New Pharmacy Policy
Policy Number	Policy Name	Summary
5.02.677	Sylvant (siltuximab)	FDA approved for Multicentric Castleman’s Disease; IV; Medical-Rx benefit; IV; Medical-Rx benefit

Pharmacy Policy with Changes

Here is a Blue KC pharmacy policy with changes for a drug that will not require prior authorization effective July 1, 2025:

Pharmacy Policy with Changes
Policy Number	Policy Name	Summary
5.02.620	Keytruda (pembrolizumab)	Updated to add mesothelioma, pleural, unresectable advanced or metastatic to list of FDA approved indications.

Commercial Formulary Updates

We want to let our contracted providers know of updates to the Blue KC Commercial Prescription Drug Lists that will go into effect on July 1, 2025.

Below are the Premium Prescription Drug List updates that will be effective July 1, 2025:

Please Note: These changes ONLY apply to members on the Premium Formulary. Group-specific benefit exceptions may apply.

New Step Therapy Requirements

Members must try preferred alternatives before other drugs will be covered.

Drug Class	Drugs Requiring a Trial of Alternative(s)	Preferred Alternatives (Try First)
Oral Contraceptives	Femlyv tablet	Any of the following generics: norethindrone/ethinyl estradiol or norethindrone/ethinyl estradiol/fe

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Cholesterol Agents	Trilipix capsule	fenofibric DR capsule
Corticosteroids	deflazacort suspension	prednisone oral solution
Miscellaneous Gastrointestinal Agents	Chenodal tablet	ursodiol tablet
Topical Anti-infectives	Crotan lotion 10%	permethrin cream

Newly Excluded Drugs (Covered Generic Equivalents are available)

Corlanor tablet	Dasliresp tablet	Evista tablet	Fosamax tablet
Intelence tablet 100 mg	Intelence tablet 200 mg	Lucemyra tablet	mesalamine kit
Proscar tablet	Rowasa kit	Sprycel tablet	Viibryd tablet

Specialty Drug Classification Changes

Now Classified as Non-Specialty Drugs
Jesduvroq tab	Vafseo tab	Xphozah tab

Below are the Select Prescription Drug List updates that are effective July 1, 2025:

Please Note: These changes only apply to members on the Select formulary. Group-specific benefit exceptions may apply.

New Step Therapy Requirements

Members must try preferred alternatives before other drugs will be covered.

Drug Class	Drugs Requiring a Trial of Alternative(s)	Preferred Alternatives (Try First)
Oral Contraceptives	Femlyv tablet	Any of the following generics: norethindrone/ethinyl estradiol or norethindrone/ethinyl estradiol/fe

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Cholesterol Agents	Livalo tablet	atorvastatin tablet, lovastatin tablet, pravastatin tablet, rosuvastatin tablet, simvastatin tablet
	Trilipix capsule	fenofibric DR capsule
Corticosteroids	delflazacort suspension	prednisone oral solution
Miscellaneous Gastrointestinal Agents	Chenodal tablet	ursodiol tablet
	mesalamine kit	mesalamine enema
Topical Anti-infectives	Crotan lotion 10%	permethrin cream

Newly Excluded Drugs (Covered Generic Equivalents are available)

Corlanor tablet	Dasliresp tablet	Evista tablet	Fosamax tablet
Intelence tablet 100 mg	Intelence tablet 200 mg	Lucemyra tablet	Oxtellar XR tablet
Proscar tablet	Rowasa kit	Sprycel tablet	Viibryd tablet

Specialty Drug Classification Changes

Now Classified as Non-Specialty Drugs
Jesduvroq tab	Vafseo tab	Xphozah tab

Below are the Essential Health Benefits (EHBs) Prescription Drug List updates that will be effective July 1, 2025:

Please Note: These changes ONLY apply to members on the EHB Formulary. Group-specific benefit exceptions may apply.

Newly Excluded Drugs (Covered Generic Equivalents are available)

Compro suppository	Motegrity tablet	Spiriva HandiHaler	Sprycel
Symbicort inhaler	Votrient tablet

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Provider Education

Blue KC to Expand Scope of High-Cost Claim Reviews with Facilities, effective September 1, 2025

Blue KC will implement enhancements to our high-cost claims process. Effective September 1, 2025, Blue KC will partner with Zelis to perform an expanded scope of reviews to ensure consistency in claims review and reimbursement practices with our facility partners. Zelis’ services will include the existing itemized bill review and Diagnosis-Related Group (DRG) review of medical records for services rendered to ensure billing and payment accuracy.

For coding and clinical validation reviews, Zelis utilizes nationally recognized coding guidelines, including ICD-10-CM/PCS Official Coding guidelines, AHA Coding Clinic, consensus guidelines and peer review articles.

What You Need to Know	In addition to Blue KC’s existing itemized bill review process for discounted charge claims, Blue KC will expand the scope of these reviews to include coding and clinical validation review of facility claims with a DRG payment methodology. This review is not based on medical necessity. Clinical validation is a distinct and separate process from coding validation. Blue KC requires submission of itemized bills with all facility claims with a billed charge of $100,000 or more with a reimbursement methodology of DRG, DRG outlier or discounted charges for inpatient and outpatient claims. Medical records and/or itemized bills may also be requested as needed to support Blue KC payment integrity audits. When a medical record and/or itemized bill is required for these high-cost claims and is not submitted, the claim will be denied, and a letter will be generated requesting additional information. A new or corrected claim does not need to be submitted because the claim will be reconsidered upon receipt of the additional information from the provider. As a reminder, all claim submissions must adhere to all applicable medical coding guidelines and Blue KC medical and payment policies. Please continue to fax the itemized bill to 816-995-1552. Beginning September 1, 2025, medical records should be faxed to 816-926-4258. Include the patient’s Subscriber ID number. At this time, the attachments cannot be submitted electronically with the claim. The claim may not be faxed to the number above, but it can be submitted electronically. Criteria for this process is: Payment methodology for the claim is based on percentage of billed charge or DRG/DRG Outlier for inpatient or outpatient claims. Interim claims are included for non-Blue KC Members. Transplant claims are excluded. Claims in which Blue KC is the secondary payer are excluded. Interim claims are excluded for Blue KC members until the final billing is submitted. At that time, the itemized bill should also be submitted.
How will Zelis Communicate Their Findings?	Zelis will send you detailed findings regarding these issues and provide you with a direct contact with whom you can discuss and resolve any issues you may have with its findings, as is our current itemized bill review process. Please contact Zelis to discuss any inquiries you may have regarding the review findings and/or the documentation and explanations necessary to clarify the charges questioned. You may also exercise your right to formally dispute Zelis’ finding. Please send all formal claim dispute correspondence directly to Zelis at: Zelis Claims Resolution providerservices.integrity@zelis.com Phone (Toll Free) 1-866-489-9444 Fax 1-855-250-3338
What Happens if the Claims Does Not Meet Criteria?	If the claim does not meet the criteria for inclusion to this program, it will continue processing. If an itemized bill and/or medical record is not received upon claim submission, the claim will be denied, and a letter will be generated additional information to be faxed to Blue KC. A new or corrected claim does not need to be submitted.

Collaborating Physician Attestation Now Part of Credentialing Application on Blue KC Provider Portal

To help provide for a more efficient credentialing process, Mid-Level Providers who practice only in Kansas and attest as such in our online credentialing application form, will be exempt from a collaborating practice agreement. For Mid-Level Providers who practice in Missouri, they still need to submit a copy of their collaborating practice agreement, as part of their credentialing process.

Providers can find our online credentialing forms by logging into Providers.BlueKC.com and clicking on Forms under Quick Links on the home page. The form is in the Provider Services section.

Enhanced EFT and ERA/835 for Provider Reimbursement

Looking for faster, safer and more efficient claim payments? Switch to Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA/835) today!

Benefits of EFT and ERA/835:

• Speed – Receive payments faster and skip the trip to the bank.
• Efficiency – Auto-posting with ERA/835 reduces manual entry.
  • No hand-keying if EMR is properly set up.
  • Easily track unpaid claims with EMR reports.
• Savings – Cut costs tied to paper checks and remits.
  • Avoid bank lockbox and imaging fees.
  • Reduce shredding costs and paper waste.
• Security & Compliance – Better protect PHI and minimize risk of lost documents or checks.

To sign up for EFT:

• Submit our Electronic Funds Transfer Authorization Agreement form online here or go to Providers.BlueKC.com. Log in and click on Forms under Quick Links. The form is in the EFT/ERA Enrollment Forms section. Additionally in that section, you will also find our helpful Frequently Asked Questions (FAQ) document to answer general questions about EFT or ERA/835.

To sign up for ERA/835:

• Please complete the following form on the website of our clearinghouse, Administrative Services of Kansas (ASK): https://www.ask-edi.com/forms/era-enrollment-bcbskc. If you have any questions about this form, the ASK EDI Help Desk is available to assist. To reach them, call 1-800-472-6481 or email ASK at askedi@ask-edi.com.

Medicare Advantage Exit Helpful Information

As of December 31, 2024, Blue KC officially exited the Medicare Advantage (MA) market. We understand this change may still raise questions, and we’re here to help. We are providing the information below to assist you in navigating this transition.

• How does this impact Medicare Advantage members who belong to another Blue Cross and Blue Shield affiliate (e.g., Blue Cross Blue Shield of Michigan) but reside in the Blue KC service area?
  • These members may continue to seek care within the Blue KC service area.
  • In many of these cases, the member’s plan will apply in-network benefits to an out-of-network claim.
  • You will want to check benefits and eligibility prior to providing services for a member.
  • Blue KC will continue to support these members through the following:
    • Provider education
    • Notification of quality-of-care opportunities
    • Collection of medical records
• What impact does this have on provider reimbursement?
  • The member’s plan is responsible for setting and determining the reimbursement.
  • Providers can expect to be reimbursed at standard Medicare rates.
  • The allowable charge will be determined based on Medicare rates.

Preventive Visits for the ACA Population

Blue KC wants to provide helpful information related to preventive visits for our Affordable Care Act (ACA) line of business. A comprehensive preventive visit is a yearly doctor's appointment focused on promoting overall health and well-being by addressing potential health risks and promoting early detection of conditions*. See the table below for age-appropriate preventative visit code sets.

AGE	NEW PATIENT CPT CODE***	EXISITING PATIENT CPT CODE***
Infant (age younger than 1 year)	99381	99391
Early childhood (age 1 through 4 years)	99382	99392
Late childhood (age 5 through 11 years)	99383	99393
Adolescent (age 12 through 17 years)	99384	99394
Adult (age 18 through 39 years)	99385	99395
Adult (age 40 through 64 years)	99386	99396
Adult** (65 years and older)	99387	99397

*Preventive visits can be billed with an evaluation and management service if there are 2 distinctly identifiable services performed and documented. Append modifier 25 to the E/M code.
**G0438, G0439, G0432 are used for Medicare Advantage population.
***Member may be subject to copay/coinsurance/deductible

Lucet Webpass Authentication Update

For your awareness, Lucet, who manages behavioral health providers for Blue KC, recently made an update that will impact providers and facilities who use Lucet’s WebPass system. This update will affect how searches are conducted for an insured member to ensure that member authentication requirements are met.

Effective May 15, 2025, WebPass users are now required to enter the Member ID Number, First Name, Last Name, Date of Birth and query date in order to search for an insured member. If any of these required fields are missing, the Lucet member will not be found in WebPass.

All WebPass users and facilities should have already received direct communication outlining this change to ensure a smooth transition.

Thank you for your continued collaboration in accurately identifying insured members and supporting the delivery of quality, coordinated care. Please reach out to providersupport@lucethealth.com if you have any questions.

HEDIS Gaps in Care Notifications

Since the fall of 2024, Blue KC has been notifying members regarding their gaps in care for select HEDIS measures. The modalities by which these gaps are being communicated currently include:

• Notifications upon logging into their member portal.
• Direct calls from Blue KC’s Community Health Workers.
• Within the digital care management application.
• When a member calls into our customer experience team.
• Within their explanation of benefits.

The intent of these communications is to increase member awareness of their existing clinical gaps and help drive compliance to closing them and increase their health outcomes by directing them to their primary care provider.

Blue KC Care Management Team – A partner in health

The Blue KC Care Management Team includes clinical nurses, social workers and Community Health Workers. They can help your patients navigate cancer, offer resources for a healthy pregnancy, manage chronic health conditions, offer support and encouragement after a diagnosis, provide assistance with transitions of care, assist patients in achieving their wellness goals and answer questions about benefits.

The team personalizes a plan based on each patient’s unique care needs. The Care Management Team continuously monitors a dashboard, which surfaces insights about preventive health needs, such as flu shots or annual eye exams, and flags patient survey responses related to their health, wellness and nutrition. Our team then works with your patients to schedule care and navigate resources.

One of the best ways to connect with the Care Management Team is through the Blue KC Care Management app. With this health resource, users can also view articles and videos personalized to them, set appointment and medication reminders, and access exclusive perks from local and national brands, including offers on groceries, health and wellness, and more.

You can encourage patients to download the Blue KC Care Management App from the App Store or Google Play. They should use access code kcnews when prompted. They can also learn more about the Blue KC Care Management app and Care Team on this page. For more information about case management services or to make a referral, call the Management Referral Line at 816-395-2060 or 1-866-859-3811.

Important Provider Information

Blue KC wants to make sure you have important information related to five key areas:

• Member Rights and Responsibilities: Blue KC members have certain rights and responsibilities. For a complete list of the Blue KC Member Rights and Responsibilities, please visit: https://Providers.BlueKC.com/Content/PDFs/PRG/BlueKCBasics.pdf.
• Utilization Management Policies: Medical and Pharmacy review criteria, along with Medical policies, are available at ttps://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf or by calling 816-395-3989.
• Pharmacy Services: Pharmacy Management policies and current information regarding classes of medications requiring prior authorization, step therapy, specialty pharmacy and/or having dose optimization/quantity limits are available by logging into the provider portal at https://Providers.BlueKC.com. In addition, explanation on limits/quotas, the steps required to initiate an exception request, and the Blue KC process for generic substitution, therapeutic interchange and step therapy protocols are accessible by logging into the provider portal at https://Providers.BlueKC.com or by contacting Pharmacy Services at 816-395-2176.
• Special Notice – How Utilization Management Operates: Blue KC’s Population Health division, Pharmacy Services, participating network physicians and providers make decisions about Blue KC members’ healthcare needs based on the medical appropriateness of the care and service. Our goal is to identify and promote cost effective usage of healthcare resources to ensure that quality healthcare services are delivered to our members. Blue KC does not reward its Utilization Management (UM) staff for issuing denial of coverage decisions. There are no financial incentives offered to UM staff to make decisions that would encourage underutilization of services. Learn more at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.
• Complex Case Management: Information on our Complex Case Management Program, including referral criteria and how to refer patients to the Program, can be found at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.

July Free Documentation & Coding Webinar

Join us for the July monthly webinar hosted by our partner, Veradigm! This is a free documentation and coding education webinar. Each 1-hour webinar is approved for one AAPC CEU when you achieve a 70% or higher on the post-test. To register for the July webinar, click here and check out these details:

July 29 & 31 7:30 am & 11:30 am CT

The Sweet Spot: Coding for Diabetes and Complications

Improve your practice’s submission of the most prevalent risk-adjustable condition and its associated manifestations. Learn documentation essentials for correctly coding juvenile onset diabetes, type I and II diabetes, secondary diabetes and diabetes due to genetic defects or post procedure. Build upon the essentials to efficiently and effectively code for manifestations, such as nephropathy, neuropathy and retinopathy.

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Community Investment

Blue KC and Boys & Girls Clubs of Greater Kansas City Partner to Prioritize Mental Health

Thanks to a partnership with Blue KC, staff at the 10 Boys & Girls Club locations in the Kansas City area can use trauma-informed practices to support the mental health of more than 5,000 kids and teens they serve each year. It’s a chance to address the youth mental health crisis following an advisory from the U.S. Surgeon General detailing kids’ declining mental health. According to the National Library of Medicine, more than two out of three children and adolescents in the United States experience trauma by the age of 16.

To learn more about Blue KC’s partnership with the Boys & Girls Clubs of Greater Kansas City, click here.

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Contact Us

Your comments are welcome and can be sent to BlueSpeak@BlueKC.com. We would love to hear from you!

Please join the BlueSpeak email distribution list by signing into the Provider Portal and then selecting “Register for BlueSpeak eNewsletter” under “Provider Service Quick Links” on the home page.

If you have questions about any of these updates, please call the Blue KC Provider Hotline at 816-395-3929 for Commercial line of business, 866-508-7140 for Blue Medicare Advantage line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

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