Provider Bulletin Q4 2025



In this bulletin, we’re delighted to invite you to our annual Provider Meetings. We’ll also share coding updates, changes to our formulary and information about our Site of Care of program, along with medical management updates and important resources. 

Save the date: Join us virtually for our annual provider meetings  

Please join Community Health Options’ Provider Experience team via Zoom at the annual Provider Meeting. You can choose from two sessions for an invaluable opportunity to connect, share updates and collaborate on key topics relevant to our provider network as we work with you to ensure our Members get the best care possible.

Meetings are scheduled for 11:30 a.m. to 1 p.m. (EST) on:

•  Wednesday, Nov. 6
•  Wednesday, Nov. 13

Please RSVP here.

We’ll send a Zoom link once you register. We look forward to your participation and appreciate your continued partnership!

Effective Oct. 15: Complete ICD-10 diagnosis codes required on all provider bills

Effective Oct. 15, Community Health Options will no longer accept claims without a complete ICD-10 diagnosis code for select diagnosis codes. Specifically, a complete ICD-10 diagnosis code represents the condition documented to the highest level of specificity and all the appropriate digits required for that condition.

Example: C90/C90.0 Multiple myeloma and malignant plasma cell neoplasm

• C90.00 Multiple myeloma having not achieved remission
• C90.01 Multiple myeloma in remission
• C90.02 Multiple myeloma in relapse

C90 and C90.0 are non-billable because they are missing the fifth digit, which provides the higher level of specificity that makes it a complete diagnosis code. As a result, claims with an incomplete diagnosis code such as C90 or C90.0 will be denied since these diagnosis codes require the additional digit to be considered complete under acceptable coding guidelines.

Formulary update: Small Group and Individual Members moving to a managed formulary

Beginning Jan. 1, 2026, Community Health Options is implementing a Managed Formulary for our Individual and Small Group populations. This update will help us to lower costs and align with broader market practices, while enabling us to provide our Members with access to the high-quality care they deserve.

Our pharmacy benefit manager, Express Scripts, will send letters to affected Members on Oct. 15 to let them know their current medications—many of them brand names—are longer be covered. The letter also directs them to talk with their providers about appropriate alternatives. The type of formulary coverage will be listed on our Members’ ID cards.

Notable changes include:

• Removing multi-source brands and select Tier 4 brands from coverage
•  Implementing a medical exception process to consider requests for coverage of excluded drugs, ensuring that Members still have a pathway to access necessary medications when clinically appropriate.

Our Large Group clients will continue with the Incentive Formulary. This means:

• You can continue to request non-preferred products through our automated utilization management system, which includes prior authorization.

• Non-preferred products may also be subject to quantity limits or step therapy requirements. This structure will remain in place through 2026.

These updates reflect our continued commitment to balancing affordability, access and clinical integrity across all lines of business.

Reminder: Our Medication Benefit Management guide will be updated as of 11/1/25 for the 1/1/26 benefit, including medical benefit and pharmacy formularies.

Blood glucose test strips: Step therapy to be updated Oct. 13

To help ensure uninterrupted access to diabetic testing supplies, OneTouch glucose test strips will move to Step 2 Non-Preferred from Step 1 Preferred beginning Oct. 13, 2025.

• True Metrix and Truetrack (Trividia) will move from Step 2 Non-Preferred to Step 1 Preferred
• Abbott Products: Freestyle, Freestyle Insulinx, Freestyle Lite, Precision Xtra will remain as Step 1 Preferred

Please note: Effective Oct. 1, 2025, continuous glucose monitoring supplied will be covered under the Pharmacy benefit and no longer covered as a medical benefit. 

Vaccine updates: COVID-19 vaccines available to Community Health Options Members

Community Health Options continues to cover the COVID-19 vaccines for all Members at 100% when billed by an in-network provider or an in-network pharmacy.

Among other updates:

• The US CDC added Penmenvy to vaccination schedule and Community Health Options will covered at 100% when billed by an in-network provider or an in-network pharmacy.
• As of Aug. 22, 2025, the FDA suspended the U.S. license for Ixchiq, the live-attenuated chikungunya vaccine (Vimkunya, the virus-like particle vaccine, remains available).

Newly Added Medications Requiring Prior Approval, effective Oct. 1, 2025

Medications that are subject to voluntary Site of Care transition are denoted with an asterisk (*).

Medications requiring Prior Approval from No PA, effective Oct. 1, 2025

Medications changed to Not Covered from No PA, effective Oct. 1, 2025

Medications no longer requiring Prior Approval, effective Oct. 1, 2025

Medications now covered under Pharmacy Benefit only, effective Oct. 1, 2025

Medications excluded at launch, effective Oct. 1, 2025

Medications now covered that were not covered, effective Oct. 1, 2025

Medications added to Site of Care Program

Medications that are subject to voluntary Site of Care transition are denoted with an asterisk (*).

Effective 1/1/2026 two codes will be moving back to Non-Covered/Experimental/Investigational:

• C9808 Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)

• C9809 Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)

Important Provider information and resources

Accessing the information you need: If you need information, our Customer Services team is available from Monday-Friday, at 855-624-6463.

If you do not have access to the provider portal, need assistance signing up or would like a paper copy of our documents, please call Customer Service.

Member Rights and Responsibilities: Read more here. 

Member Support: Community Health Options provides a comprehensive range of care management services tailored to the specific needs of your patients. Our dedicated team comprises nurses, social workers and care navigators who can support your patients with complex medical needs including physical, behavioral and psychosocial health conditions. You can also easily refer your patients to our specialized Chronic Illness Support Program, for patients with asthma, hypertension, diabetes, COPD and coronary artery disease by contacting our Customer Service Team at 855-624- 6463.

Pharmacy Benefit: Our formulary is updated monthly, so to ensure a prescribed medication is covered and minimize Member out-of-pocket cost, we recommend you consult the formulary when writing a prescription. Find our formulary here.

Pharmaceutical management information can be found in the Medication Benefit and Management Guide, or our formulary. Guide topics include a list of pharmaceuticals, including restrictions and preferences, how to use the pharmaceutical management procedures, an explanation of limits or quotas (if any), how prescribing practitioners must provide information to support an exception request, and the process for generic substitution, therapeutic interchange, and step-therapy protocols.

Utilization Management: You always have access to our team for questions about utilization management, Prior Approval requirements, and the availability of clinical criteria for review upon request. For information, call 855-624-6463.

Affirmative Statement: Community Health Options coverage decisions are based on the appropriateness of care and the existence of benefits. Community Health Options does not incentivize our employees or contracted Providers to improperly deny or withhold Benefits. Community Health Options staff involved in Prior Approval decisions must sign a conflict-of-interest statement each year.

Resources  

Urgent Care Provider Sheet 

Company Profile 

Availity Portal 

Community Health Options Website Provider Resources  

Community Health Options’ Provider Network 

If you have any questions

please email:

provider@healthoptions.org