FAQ

BlueCross Specialty Drug Process FAQs

We understand you may have questions about this process change. Here’s some additional information, including contact information if you need more help.

 

Q. Why are we making this process change?
BlueCross and the Tennessee-based employers we serve paid $975 million for provider-administered specialty drugs in 2019. And these employer group customers are asking us to help them better manage these costs.

By requiring providers to use our specialty pharmacy network, we can make sure our members get better prices. Any savings will go directly to Tennessee employer groups and their employees (our members), not BlueCross or a pharmacy benefit manager (PBM).

 

Q. Which drugs are included in this process change?
This 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. You can see the list of provider-administered drugs here.

 

Q. Does the process change apply to every BlueCross health plan?
The process change applies to members in many of our self-funded employer-sponsored plans. (Those are plans where the employer directly funds the cost of its employees’ medical care, and uses BlueCross for its network, administrative and care support services.)

It does not apply to Individual/Marketplace, Medicare Advantage, BlueCare, and BlueCare Plus plans yet. Members in these plans should simply follow the same process as before.

Please contact us at the member service number on the back of your member ID if you have questions about whether these changes apply to you.

 

Q. Why are some providers opposed to this change?
Some providers have expressed operational concerns about the new process, which we’ve worked to address during the transition period. But some don’t like this new process because they’ll lose revenue from buying and billing us for these drugs. (We’re still paying them for the service of administering the drug.) But the change, simply put, helps us keep prices lower because our specialty pharmacies have agreed to much more competitive pricing.

 

Q. What are you doing to help members whose providers object to this change?
We’re having ongoing discussions with providers who have expressed concerns about the changes. We want to make sure they understand the process, as well as what drugs are included and which members are affected.

(Despite our best efforts, there’s been some confusion among providers who think these changes apply for every kind of drug and every member.)

It’s important for you to know that, after the Advanced Specialty Benefit Management (ASBM) program went into effect Jan. 1, 2020, we created a six-month transition period and more options for providers to participate in this program. 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.

We’re continuing to expand our specialty pharmacy network, and we’re helping members identify new providers to administer their treatments if necessary.

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.

 

Q. What will change as of July 1, 2020?
Beginning July 1, 2020, our six-month transition period is over and we’re requiring providers to follow the new process to get these medications. 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 a reminder, specialty pharmacies in our specialty pharmacy network can safely ship drugs anywhere in the country within 24 hours.

 

Q. How has the COVID-19 pandemic affected this program’s implementation?
The pandemic has not affected our timeline. But as many companies struggle through the resulting economic slowdown, the chance to save up to 20% on an expensive class of medications is even more important.

 

Are you a member being treated with specialty drugs?

Here are some answers to questions you may have.

 

Q. Can I still go to the same doctor to receive treatment?
Yes, if they’ll continue to serve you while following this new process. If your provider is unwilling to do so, let us know and we’ll help you identify a new provider.

We’re not asking you to change where you get care. We’re asking your doctor to obtain the drugs in a different, more cost-effective way.

 

Q. What if my doctor doesn’t get my medication through a pharmacy in your specialty pharmacy network?
Members and/or their providers may ask us for an exception, which we’ll grant only if:

    • There isn’t another provider in your network within 50 miles of your residence.

    • Delaying your treatment would harm your health – one exception per member only.

    • Your treatment is urgent and your drug wouldn’t arrive in time – one exception per member only.

 

Q. Will the specialty pharmacy send the medication directly to me?
No. Your health care provider is still responsible for ordering and taking delivery of these drugs. The only difference is they will be shipped from an in-network specialty pharmacy instead of a wholesaler. All our in-network specialty pharmacies can deliver medications within 24 hours of your appointment time.

Some providers have claimed that we’re requiring drugs be shipped directly to patients – which has caused our members to worry unnecessarily. Members will never have to bring their medication with them to their appointment.

 

Q. How will my doctor acquire these drugs for me under the new process?
Your doctor will send your contact information to the pharmacy supplying the drug. The pharmacy will contact you, and will let you know when the drug will be available at your doctor’s office.


How long does my doctor’s office have to wait to receive the drugs from the specialty pharmacy?
All our in-network specialty pharmacies can deliver medications within 24 hours. We hold them accountable to ensure they prepare drugs properly for shipping and deliver them on time.

 

Q. What if the specialty pharmacy doesn’t have my medication?
Remember, your physician is responsible for ordering these drugs, not you. And we’ll work with them to make sure you get the medication you need. If necessary, we’ll get it through a different specialty pharmacy in our network.

 

Q. Have you communicated with my doctor about this change?
Yes. In late 2019, we sent a letter to your health care provider so they could have plenty of time to prepare for following this new process Here’s a sample letter so you can see what we told them.

In May 2020, we sent an additional letter to your provider reminding them that our transition period would end June 30, 2020. Here’s a sample letter so you can see how we followed up.

 

Q. My provider says BlueCross is forcing them to send me elsewhere for my treatment. Is this true?
No. If your provider is unwilling to continue serving you, call the number on the back of your BlueCross Member ID card. We’ll help you find a new location to get your treatments.

 

Q. Is this a safe way to get the medication that I need?
Yes. We have contracts in place to ensure drugs are stored, handled and shipped properly.

 

Q. How can this program save me money?
Since costs are expected to be lower for these specialty drugs, the share you’re responsible for paying should be lower too.

Here’s an example using the specialty drug Remicade:

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.

 

Q. Will I have to pay for my specialty drug up front?
You may need to pay the pharmacy before they ship the drug to your doctor’s office. Although you may pay a few days sooner than usual, you may pay less than you’re used to.

Pharmacies in our specialty pharmacy network accept payment via credit/debit cards, HSA cards, personal checks, money orders, cashier’s checks, and payment plans. You can still use manufacturer coupons and/or copay assistance programs to lower your out-of-pocket costs for your provider-administered specialty drugs.

In some cases, doctors who administer the drugs may be in our specialty pharmacy network. If so, you may still be able to pay your doctor for the drug directly, and may not experience any changes.

 

Q. Will this program affect copay assistance?
Copay assistance programs are still available to you. They’ll be processed through the specialty pharmacy network instead of doctors’ offices.

 

Q. Does the specialty pharmacy provide any extra benefits?
Yes. When you work with our specialty pharmacy network, you’ll have access to patient care coordinators, educational materials and phone-based clinical pharmacists who can give advice.

 

Q. What if I want to go somewhere else (such as home infusion) for these drugs?
You can still get care from any other provider in your network, including providers who offer drug infusion in your home.

 

Q. What is a specialty pharmacy?
A specialty pharmacy is designed to deliver drugs that require special handling, storage and distribution (defined by the Academy of Managed Care Pharmacy). They work closely with physicians, so they get the exact drug and usage instructions patients need.

All pharmacies in our specialty network can deliver medications within 24 hours. We hold them accountable to make sure they prepare drugs properly for shipping and deliver them on time.

 

Q. Whom can I call with questions?
If you need help with a specialty pharmacy prescription, please call the Member Service number on the back of your BlueCross Member ID card.

 

Are you a Tennessee-based employer?

Here are some answers to questions you may have.

 

Q. How will this program benefit my employees and my company?
The short answer is that you’ll both save money. We provide coverage for more than 11,000 Tennessee-based companies. Many of them have told us how challenging it is to keep up with rising drug costs, and they’ve asked us to help.

Specialty drugs that are administered by health care providers are valuable for our members. They’re also expensive treatments – and our program will make sure they’re delivered cost-effectively.

 

Q. Will my employees and their family members need to change where they get care?
Only if their providers refuse to treat them while following our new requirements.

We’re not asking members to change where they get care. We’re asking providers to help them save money by obtaining specialty drugs through our specialty pharmacy network.

Our specialty pharmacy network will work closely with physicians, so they get the exact drug and usage instructions our members need. But some providers don’t like this new process because it takes away their ability to add markups to drug costs.

 

Q. Why are some providers opposed to this change?
Some providers have expressed operational concerns about the new process, which we’ve worked to address during the transition period. But some don’t like this new process because they’ll lose revenue from buying and billing us for these drugs. (We’re still paying them for the service of administering the drug.)

But the change, simply put, helps us keep prices lower because our specialty pharmacies have agreed to much more competitive pricing.

You can read more in our Q&A with our director of pharmacy, our vice president of provider contracting, and our vice president of sales and account management.

 

Q. Whom can I contact with questions?
If you have questions or need more information, please contact your BlueCross BlueShield of Tennessee Sales or Account Executive.

 

Are you a health care provider?

Here are some answers to questions you may have.

 

Q. How will providers and patients benefit from using our specialty pharmacy network?
Providers will receive extra support services to help manage member care: 

  • Patient care coordinators

  • Ability to consult with clinical pharmacists

  • Compliance management programs to help optimize treatment

  • Disease management programs to actively monitor and manage complex drug regimens

  • 24-hour drug delivery to their office

Providers will also benefit from streamlined processes that enable:

  • Reduced need to maintain an inventory of specialty medications

  • Smoother billing and reimbursement, since they’ll be working with a pharmacy benefit management system – not a medical one

  • Continuity of care; patients won’t have to go anywhere else for medicine or treatment

 

Q. Will we be able to get drugs quickly and accurately?
Yes. All the specialty pharmacies in our network can deliver medications within 24 hours, and they’ll work with you to make sure you get the correct drug and dosage for your patients.

We hold our specialty pharmacies accountable to make sure they prepare drugs properly for shipping and deliver them on time.

 

Q. What about drugs that require temperature control?
The specialty pharmacies in our network have sophisticated systems for making sure these drugs, such as Lucentis and Eylea, are packaged and shipped in a way that maintains the proper temperature and stability of the medications.

Some drugs are shipped with a temperature card for verification purposes. And if a drug’s stability is in question upon arrival, the provider can request a replacement order with a temperature sensor card.

 

Q. What if a provider plans to use an out-of-network pharmacy?
When providers call for prior authorization, they’ll be directed to order the drug through our specialty pharmacy network. If a provider forgets to call for prior authorization or decides to use an out-of-network pharmacy, we’ll deny the claim.

 

Q. Is BlueCross changing provider contracts?
No. We are simply changing our process to make these drugs more cost-effective for our members.

 

Q. Whom can I contact with questions?
If you would like additional information, please contact your Network Manager or our Provider Service line at 1-800-924-7141.