BCBST News Center
Jan. 8, 2020
You may have heard about changes we’re making about how we cover specialty medications that are administered by health care providers. It’s a complicated topic, and we want to help make sure you understand a few important points.
Here are seven things you need to know about our specialty pharmacy program.
- Our changes will save money for some Tennessee-based employers and the people covered by their health care plans.
- We’re not making any changes to what types of medications we cover.
- We’re not asking members to see a different doctor or receive care at a different facility.
- We’re not asking members to order or handle these medications themselves.
- We’re still going to pay health care providers for their services to administer these drugs to our members.
- We’ve adjusted our plans to address operational concerns expressed by some providers.
- These changes only apply to about 5,500 of our 3.5 million members.
Let’s dive into each of these key facts.
1. Our changes will save money for some Tennessee-based employers and the people covered by their health care plans.
Self-funded employer groups have asked for our help managing these drug costs. They pay for their employees’ health care themselves, but use BlueCross networks and services. That means any savings generated in the specialty pharmacy program that went into effect Jan. 1 will go directly to these employers and the members they cover – not BlueCross.
In 2018, the Tennessee-based employers we serve paid $900 million for provider-administered specialty drugs.
Members covered by these plans can also see direct savings, especially if they have high-deductible health plans.
2. We’re not making any changes to what types of medications we cover.
We’re changing the process providers use to obtain certain kinds of medication, but we aren’t changing the list of drugs we cover. Our process change affects all provider-administered specialty drugs on our covered drug list. It doesn’t include any self-administered specialty drugs delivered to members’ homes.
3. We’re not asking members to see a different doctor or receive care at a different facility.
We value the relationships our members have with their providers, and we don’t want to disrupt how they get treatments. We’re just asking providers to help our members save money by obtaining specialty drugs in a different way.
All the specialty pharmacies in our network can deliver medications anywhere in the U.S. within 24 hours. The specialty pharmacies in our network have contracts in place that hold them accountable for proper preparation and delivery of these drugs, including factors like temperature control.
Our new process is not substantially different from the physician receiving medication shipments from a wholesaler, which is how they ordered in the past. It doesn’t present new risks – or lead to more wasted drugs.
We’ve had a specialty pharmacy network for years, and we’ve been adding more pharmacies to the network. We do not require a provider to use one particular pharmacy in our network; any pharmacy in the specialty network may be used.
4. We’re not asking members to order or handle these medications themselves.
These are drugs administered by providers, and we don’t want members to be responsible for obtaining them.
Here’s how the new process works: A provider orders the medication and schedules an appointment for our member. After that, the specialty pharmacy will call the member to answer any questions they may have about the prescription and arrange payment. After the member pays, the specialty pharmacy will ship the drug to the provider and the member will go to their appointment as normal.
If the member is unable to pay right away, the specialty pharmacy will ship the drug to the provider and create a payment plan – or find copay assistance – for the member.
5. We’re still going to pay health care providers for their services to administer these drugs to our members.
We recognize that providers provide expertise and care — and that they have operating costs associated with that care. We reimbursed them for their services under the old process, and we aren’t changing that.
We’re asking providers to obtain their drug shipments from a different source because these drugs have become more expensive – and more common. Together, we can help members get these important drugs at the best possible prices.
6. We’ve adjusted our plans to address operational concerns expressed by some providers.
While we’re confident in these steps forward, we acknowledge there’s still work to be done — that’s why we’re having ongoing discussions with providers. We want to make sure they understand the process, as well as what drugs are included, which members are affected, and any treatment timelines that may be impacted.
Some of the steps we’re taking include instituting six-month transition program — providers have until June 30, 2020 to fully transition member care to this new program — and adding opportunities for providers to participate in our specialty pharmacy network.
We’re also evaluating our provider network to find alternative providers for members whose current providers still refuse to continue offering their treatments.
And our network management, customer service and clinical support teams are working together to provide care coordination and transition of care services to members who need them.
7. These changes only apply to about 5,500 of our 3.5 million members.
Currently 100 self-funded employer groups are taking part in our specialty pharmacy program, with more to be added. Within those 100 groups, about 5,500 members receive provider-administered specialty drugs and are affected by this change.
If you’re one of the members affected, the specialty pharmacies in our network are ready to work closely with your physician to deliver the exact drug and usage instructions you need. If you need help with a specialty pharmacy prescription, please call the Member Service number on the back of your BlueCross member ID.
Visit bcbstworksforyou.com for more information.