BlueCross Is Asking Providers To Help Us Save Our Members Money

We’re focused on the health of our members, and we also have a responsibility to be good stewards of their health care dollars. In 2019, we asked health care providers to join with us to address one rapidly growing cost driver: provider-administered specialty drugs. Our specialty pharmacy program began Jan. 1, 2020.


We’ve working with self-funded employer groups to change the process for how some members pay for specialty drugs they receive at a health care facility.

  • We’re not asking members to change where they get care. We’re asking providers to obtain the drugs in a different, more cost-effective way.

  • We’re still paying providers for their services to administer these drugs.

  • Our new process is similar to how providers serve members of other health plans.


Why we’re making this change


There are two ways providers can get these specialty drugs.

  1. Buy them from a wholesaler, then bill BlueCross and the patient.

  2. Order them from a specialty pharmacy in our network, who will bill BlueCross and the patient.


We’ve allowed providers to use either method. Many of them choose to “buy and bill,” typically adding a large markup to the drug price. (We’re still paying them for the service of administering the drug.) These drugs weren’t always as expensive – or as common – as they are today, so allowing providers to “buy and bill” wasn’t as big an issue. The change, simply put, helps us keep prices lower because our specialty pharmacies have agreed to much more competitive pricing.


However, BlueCross and the Tennessee-based employers we serve spent $975 million on provider-administered drugs in 2019. There are more of these medications in development than any other kind of drug, and their costs are rising most rapidly.


BlueCross and providers have a shared responsibility to help members get these drugs at the best possible price. That’s why, as of July 1, 2020, we’re requiring providers to obtain them from our specialty pharmacy network.


This change began Jan. 1, 2020, for some members (including some with self-funded employer coverage).


Why some providers are upset about the change


Some providers don’t like this new process because it takes away their ability to add markups to drug costs. But the change, simply put, helps us keep prices lower because our in-network specialty pharmacies have agreed to much more competitive pricing. As prescription drug costs have continued to rise, the Tennessee-based businesses we serve (and our members) have asked us to help manage the costs.


We’re still paying providers to serve patients by administering the drugs. And having the drugs shipped from a specialty pharmacy isn’t a disruption compared to having them shipped from a wholesaler. Our in-network specialty pharmacies can deliver within 24 hours.


To help with the administrative process, we’ve created a six month transition period and more options for providers to adjust their operations and participate in this program. During this time, many providers have shared constructive feedback about the new process, and we’ve continued our conversations with them and adjusted our program. For example, we’ve further expanded our specialty pharmacy network. One large hospital system and six infusion centers have joined. And we’re offering “dispensing provider agreements” that will let providers continue to “buy and bill” for specialty drugs, but at the same rates as our in-network specialty pharmacies.


Providers have until June 30, 2020 to fully transition member care to this new program. We’ve also added opportunities for providers to participate in our specialty pharmacy network.


Here’s the letter we sent to providers to explain the change.

Here’s the follow-up letter we sent to providers, reminding them of the end of the transition period.


How this change helps our members – and Tennessee employers


If the drug is less expensive through our specialty network (and it usually will be), members will save on their share of the costs. Members will pay the specialty pharmacy instead of their health care provider, typically a few days earlier than they do today.


Here’s the letter we sent to members affected by the change.

Here’s the follow-up letter we sent to members, reminding them of the end of the transition period.


We’re rolling out this change first with some “self-funded groups,” which are organizations that pay for their employees’ health care themselves, but use BlueCross networks and services. Ultimately, these groups, as well as the members covered under their plans, are the ones who’ve been paying large markups. Any savings will go directly to Tennessee employee groups and their employees (our members).


Our program will continue to provide safe, convenient access to these important medications while generating savings that go directly to Tennessee employers and the members they cover. As many companies struggle through this economic slowdown, the chance to save 20% on an expensive class of medications is critical. But we’ve also taken to heart what we heard from providers and put new options in place so they have more ways to partner with us.


How members will save money


We’ll use the specialty drug Remicade as an example.


Provider buys and bills

Average cost for drug
Average cost patient pays (20%) out-of-pocket for drug

Provider orders through specialty pharmacy

Average cost for drug
Average cost patient pays (20%) out-of-pocket for drug

Savings for BlueCross members

$400 per treatment

Remicade, which can be used for certain auto-immune conditions like rheumatoid arthritis, is typically administered every eight weeks (six or seven times per year). Under the specialty pharmacy program, the annual member savings would be between $2,400 and $2,800.


Does this affect me?


If you’re currently being treated with one of these drugs – and your plan includes this new benefit – we’ve already reached out to you directly with a letter or phone call. This change applies to all provider-administered specialty drugs on the list and (see the list) for members with certain kinds of coverage. If you do not have a prescription for these types of drugs, this will have no impact on your day-to-day prescriptions.


We’re here for you


If you use specialty drugs and have any questions about this change and how it may affect your care, we’re here to help. Just give us a call at the Member Service number listed on the back of your BlueCross Member ID card.