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.
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.
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 were given 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.
On July 1, 2020, our six-month transition period expired. Providers are now required 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.
Are you a member being treated with specialty drugs?
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.
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.
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.
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.
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.
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.
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.
Are you a Tennessee-based employer?
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.
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.
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.
Are you a health care provider?
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
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.
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.