Quality articles March 2025

According to the CDC, cancer is the second leading cause of death in the U.S. Between 30% and 50% of cancer cases are preventable. We cover a variety of preventive services, including cancer screenings, at no cost (no copay and no deductible) to our members. Preventive screening services can help detect cancers in early stages, when treatment is more likely to be successful.

Screening coverage for commercial members

• Breast cancer prevention counseling (for those at high risk) and screening mammogram (ages 40+ or at high risk)
• Cervical cancer screening (Pap smear test) (ages 21+)
• Colorectal cancer screening (ages 45+)
• Lung cancer (ages 50-80 with history of smoking)
• Skin cancer counseling (ages 6 months-24 years for those with fair skin type)

Preventive vs. diagnostic care

When scheduling appointments, please remind your patients that during the preventive care visit, if diagnostic care is needed to treat a new symptom or an existing problem, cost share (e.g., copay, coinsurance or deductible) amounts may apply for these additional services.

View our preventive care lists

• Commercial members (available in English and Spanish)
• Medicare members
• Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members (lists annual physical exams and other preventive care services that are covered when BCBS FEP members seek services from Preferred providers)

Earn incentives for preventive care visits

By opting in to participate in our Medicare Advantage incentive programs, you can earn incentives for completing preventive care visits and annual wellness visits with your attributed Medicare Advantage patients.

By opting in to participate in our Commercial Quality Incentive Program, you can earn incentives for completing breast cancer screenings, cervical cancer screenings and colorectal cancer screenings for your Individual on-exchange patients.

Member reminders for colorectal cancer, breast cancer and cervical cancer

Eligible members—including Medicare Advantage, fully insured group and Individual, and administrative services only (ASO) members—may receive opt-in texts asking whether they would like to receive preventive screening reminders. If the member agrees, they receive a text message emphasizing the importance of the screening and letting them know they might be due and should make an appointment. The member can respond to the text to request help scheduling their appointment. The member’s request triggers a call from a Regence care advocate to help the member find a provider or schedule an appointment.

Best practices and member flyers

Our Quality Improvement Toolkit includes best practices and resources you can share with your patients that address the importance of breast, cervical and colorectal cancer screenings.

Claims submission

Learn more about preventive services modifiers and codes.

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Many factors influence members’ experience with obtaining medications and adhering to their treatment plan. We are increasing the support and assistance we offer for members to improve their health outcomes and experience.

Sometimes members are prescribed medications they cannot obtain for various reasons (e.g., cost, nonformulary, pre-authorization or step therapy requirements or medications excluded from coverage). These barriers can lead to untreated or poorly controlled conditions and impact the quality of care the patient feels they received.

Look for the Medications and member experience with medications category in the Quality Improvement Toolkit. The toolkit includes best practices and action items, along with a variety of flyers you can share with your patients.

Helping your Medicare Advantage patients
To help your patients get their needed prescription medications, consider the following:

• Look up your patient’s formulary to determine coverage and cost information:
  • Selecting a drug in Tier 1 or a generic drug will decrease costs for your patient.
    • If pre-authorization or formulary exception is required, submit a request before prescribing the treatment.
    • Take quantity limits into consideration.
• Prescribe a 100-day supply for chronic medications (e.g., non-insulin diabetes medications, antihypertensives, statins). Patients who receive a 100-day supply of medication can improve adherence, save time with reduced trips to the pharmacy, and potentially save money. When filling Tier 1 and Tier 2 medications, a 100-day supply costs the same as a 90-day supply, giving patients 10 extra days of medication at no additional cost.
• If you prescribe an over-the-counter (OTC) medication, remind your patients that they may have OTC benefits. They can call the number on the back of their insurance card to find out.
  • Avoid prescribing CMS-excluded drugs. These include but are not limited to:
  • Fertility drugs
  • Nonprescription drugs
  • Drugs used for anorexia, weight loss or gain
  • Drugs for symptomatic relief of cough and colds
  • Drugs used for cosmetic purposes or hair growth
  • Drugs for the treatment of sexual or erectile dysfunction
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride
• If the patient has difficulty with transportation, consider sending the prescription to a home delivery pharmacy or a pharmacy that delivers. Amazon Pharmacy is our preferred home delivery pharmacy for Medicare Advantage members:

Amazon Pharmacy Home Delivery
Phone: 1 (855) 206-3605
Fax: 1 (512) 884-5981

Express Scripts Home Delivery
Phone: 1 (833) 599-0451
Fax: 1 (800) 837-0959

AllianceRx Walgreens Pharmacy
Phone: 1 (888) 832-5462
Fax: 1 (800) 332-9581

Postal Prescription Services
Phone: 1 (800) 552-6694
Fax: 1 (800) 723-9023

PillPack by Amazon Pharmacy
Phone: 1 (855) 745-5725 ext 3

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As a health care provider, you know that medical care alone doesn't determine a patient’s health outcome. The environments where people live, learn, work and play have a profound impact on their well-being. These factors, known as social determinants of health (SDoH), are crucial pieces of the health care puzzle. Understanding and addressing SDoH leads to better outcomes and helps close critical health equity gaps in our communities.

SDoH ICD-10-CM Z

The SDoH ICD-10-CM Z codes make it possible to measure social risk factors and social needs. They add greater specificity to capture a more holistic view of a patient’s health. Implementing SDoH in your practice documentation through ICD-10-CM Z codes is essential for:

• Creating comprehensive patient care plans
• Identifying community resource needs
• Supporting population health initiatives
• Improving health equity

View the Social Determinants of Health Z codes flyer, which includes a list of the codes that measure social risk factors and social needs.

Best practices

• Screen patients using standardized SDoH assessment tools
• Document findings using appropriate Z codes
• Connect patients with community resources
• Follow up on referrals and support services

Provider resources
Our Health Equity Toolkit includes resources for you to learn more about health disparities, and to develop and improve your cultural competency and health literacy best practices as you and your staff provide care for our members.

The Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) SDoH quality improvement provider toolkit includes an SDoH ICD-10-Z Codes Provider Coding and Reference Sheet for Practitioners and Coders.

Patient resources

• 211.org for community support services
• FindHelp.org for local resources
• Customer service support by calling the number on the back of their member ID card

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Every health care journey deserves a roadmap. National Healthcare Decisions Day, April 16, 2024, empowers providers and patients to create that map together through meaningful conversations about future care preferences.

Why It matters
Advance care planning (ACP) isn't just about end-of-life decisions —it's about ensuring your patients' voices are heard at every stage of their health care journey. These vital conversations help align medical care with personal values and wishes, providing peace of mind for patients and their families.

Getting reimbursed for these important conversations
We support these crucial discussions by reimbursing for ACP conversations with members, regardless of age or health status.

• Note: Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members have different benefits. Please consult the BCBS Service Benefit Plan brochure for details.

Key elements of ACP discussions

• Helping patients choose a trusted medical decision-maker
• Exploring current health status and future possibilities
• Understanding personal values and beliefs that shape care decisions
• Creating or updating essential documents (health care representative, advance directives, POLST/MOLST forms)

Medicare Advantage benefits
For Medicare Advantage members, we've enhanced access to these important conversations:

• $0 copay for ACP discussions
• Coverage for both telehealth and in-person visits
• One ACP conversation per day with no annual limit
• Reimbursement for CPT 99497 or 99498

Tools for success
Access these valuable resources to enhance your ACP discussions:

• Serious Illness Messaging Toolkit
• National POLST Paradigm
• The Conversation Project
• Vital Talk

Learn more
Our Personalized Care Support Program is a comprehensive set of benefits and supports available to members living with serious illness and their caregivers. Our vision is that every person living with serious illness will experience personalized care that is consistent with their values, goals and preference; and caregivers will feel included, honored and supported.

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Be sure to update patient records to document statin use for your:

Medicare Advantage patients who have diabetes or clinical atherosclerotic cardiovascular disease (ASCVD)
Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) patients who have ASCVD

For patients who have demonstrated an intolerance to statins in the past, it is important to document it during a provider visit each year with the appropriate ICD-10 code. The codes that can be used to indicate statin intolerance are listed below.

In most electronic medical records (EMRs), statin intolerance needs to be added to the billing diagnoses, addressed in the assessment/plan section of the encounter note, and added to the problem list for the exclusion diagnosis to be submitted to us in a claim. Note: Documenting statin intolerance in the allergy list does not route the code to us.

Providing these codes on claims or supplemental data files helps us identify patients who could benefit from the addition of a statin and minimize education to those patients who have demonstrated an intolerance. This will also limit the amount of information sent to you regarding your patients who are listed with gaps for this measure because we do not have information that indicates an exclusion.

Notes:

• Diagnosis codes must be submitted each year to exclude the patient from the statin quality measures.
• Exclusion conditions do not always need to occur in the same year the code was billed. The medical record can reflect the patient has a history of these conditions.
• Medicare Advantage incentive programs
• BCBS FEP provider toolkits

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Tobacco use is the leading cause of preventable disease, disability and death in the U.S. We measure the rate at which our members are advised to quit smoking. Currently, our score for this CAHPS/HOS measure is lower than national benchmarks, indicating that this is an area of opportunity for us. Providers play a key role in helping patients decrease tobacco use by introducing and encouraging the use of tobacco cessation tools and resources.

Integrating treatment into your routine clinical workflow and engaging the entire health care team in treatment delivery can make a difference.

Quality Improvement Toolkit

Our Quality Improvement Toolkit includes information about best practices and action items to help you support your patients, including:

• Advising patients to quit using tobacco products
• Offering treatment options, such as counseling and/or medication
• Referring to community resources, such as support groups
• Following up and assessing progress overtime

In addition, the toolkit includes Healthwise Knowledgebase flyers in English and Spanish for you to share with your patients.

In the toolkit, select Tobacco cessation from the Categories dropdown list.

The CDC’s Smoking and Tobacco Use hub

The CDC has information for health care providers, including guidance for care settings, clinical tools and cessation support materials to give to patients.

Tobacco cessation resources for Regence members

Pelago’s virtual clinic empowers patients (18 and older) to overcome their tobacco use through 12 months of access to their program through their app. Once registered, members receive an onboarding call from a certified tobacco treatment specialist; ongoing one-on-one coaching; guided online sessions; and nicotine replacement therapy. They may also have access to additional virtual programs for managing or ceasing tobacco use.

It is available as a buy-up program for administrative services only groups (ASO) with 51+ employees and is available to Uniform Medical Plan members. Members can learn about their benefits by logging in to regence.com or calling Customer Service at the number on the back of their member ID card.

Tobacco cessation resources for Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members

When BCBS FEP members enroll in the Blue Cross and Blue Shield Service Benefit Plan Tobacco Cessation Incentive Program, they receive daily tips and support from the online health coach and tobacco cessation drugs at no cost when using a preferred retail pharmacy.

Note: To receive benefits for over-the-counter (OTC) smoking and tobacco cessation drugs, members must have a physician’s prescription for each OTC drug, which must be filled at a preferred retail pharmacy. Regular prescription drug benefits apply to smoking and tobacco cessation drugs that do not meet these criteria.

FEP Blue Focus, Basic Option and Standard Option members can attend smoking and tobacco cessation classes at no charge when provided by a preferred provider.

Members may also be eligible to earn wellness incentives.

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