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).

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.

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.

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.

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.

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.

On Jan. 1, 2022, we expanded our Advanced Specialty Benefit Management (ASBM) program to cover all fully insured group plans (except grandfathered), level-funded group plans, and on-/off-Marketplace plans. Our ASBM program takes advantage of lower pricing that’s already available from our preferred specialty pharmacy network, saving our members money without disrupting their care.

Previously, providers could order these drugs from the pharmacy of their choice. As of Jan. 1, as part of the authorization process, a preferred specialty pharmacy will ship all provider-administered specialty drugs directly to the provider within 24 hours of order. Members will pay the pharmacy before the drug is shipped instead of paying the provider at the time of the service. This eliminates potential markups between the supplier and the member.

As an alternative, in-state providers who sign specialty pharmacy billing contracts with us may continue purchasing the specialty medications from a wholesaler and bill us for them through a web-based portal at the same rates as the specialty pharmacy network. This has allowed those providers to maintain current operational practices and still pass the savings to our members.

On Jan. 1, 2022, we expanded our Advanced Specialty Benefit Management (ASBM) program to cover all fully insured group plans (except grandfathered), level-funded group plans, and on-/off-Marketplace plans. Our ASBM program takes advantage of lower pricing that’s already available from our preferred specialty pharmacy network, saving our members money without disrupting their care.

Previously, providers could order these drugs from the pharmacy of their choice. As of Jan. 1, as part of the authorization process, a preferred specialty pharmacy will ship all provider-administered specialty drugs directly to the provider within 24 hours of order. Members will pay the pharmacy before the drug is shipped instead of paying the provider at the time of the service. This eliminates potential markups between the supplier and the member.

This program affects only specialty drugs administered in a provider’s office or facility, not self-administered specialty drugs delivered to members’ homes.

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.

Previously, providers could order these drugs from the pharmacy of their choice. As of Jan. 1, as part of the authorization process, a preferred specialty pharmacy will ship all provider-administered specialty drugs directly to the provider within 24 hours of order. Members will pay the pharmacy before the drug is shipped instead of paying the provider at the time of the service. This eliminates potential markups between the supplier and the member.

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 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 these types of medications with them to their appointment.

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.

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

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.

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.

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.

Yes. We have contracts in place to ensure drugs are stored, handled and shipped properly.

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 will 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. This program affects only specialty drugs administered in a provider’s office or facility, not self-administered specialty drugs delivered to members’ homes.

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.

Copay assistance programs are still available to you. They’ll be processed through the specialty pharmacy network instead of doctors’ offices.

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.

You can still get care from any other provider in your network, including providers who offer drug infusion in your home.

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.

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

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.

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.

If you have questions or need more information, please contact your BlueCross BlueShield of Tennessee Sales or Account Executive.

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.

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.

No. We are simply changing our process to make these drugs more cost-effective for our members.

If you would like additional information, please contact your Network Manager or our Provider Service line at 1-800-924-7141.