BCBS Offers Specialty Drug Solution

The specialty drug solution?  Require providers to buy from us…….

BlueCross BlueShield of Tennessee Makes Specialty Pharmaceuticals More Affordable for Self-Funded Employers and Others

MyHealthGuide Source: Henry Smith, 12/23/2019, The Tennessean

For patients with potential life-threatening illness, specialty drugs administered by their physicians often allow them to enjoy a quality of life they might not otherwise have.

While these medications show how far medical science has come — there are more provider-administered specialty drugs in development than any other kind of drug — BlueCross BlueShield and the Tennessee-based employers we serve paid $900 million for provider-administered specialty drugs in 2018.

Though these drugs are used by only a small number of patients, all insured people help shoulder the cost — and that cost is becoming unsustainable. Specialty drugs account for about 1% of prescriptions covered by BlueCross BlueShield but account for about 50% of our total drug spending — and that number is growing rapidly. Furthermore, a large number of specialty drugs are in the pipeline to gain approval over the next few years.

Our customers are asking us to do more to help them manage these costs. Our solution is to require providers to order specialty medications from a pharmacy in our specialty network.

Our pilot program will roll out Jan. 1, 2020, with many of our self-funded employer group customers who have opted in. These groups pay for their employees’ health care themselves but use BlueCross BlueShield networks and services. At any given time, about 1% of their employees receive provider-administered specialty drugs and will be affected by this Jan. 1 change.

Remicade Example

An example of a provider-administered specialty medication is Remicade, which can be used for certain autoimmune conditions like rheumatoid arthritis. More than 2,000 of our members used this drug in 2018, and treatment plans can range from six to 12 infusions each year. Under our specialty pharmacy network, the cost of an average infusion is $2,000 less than the current reimbursement.

We’re not asking members to change where they get care, or requiring specialty drugs be sent to their homes. Our goal is to minimize changes for our members. Rather, we’re asking providers to help members save money by obtaining specialty drugs in a different way.

One change for members

This new approach requires only one change: To ensure the provider will have the drugs at the time of their visit, BlueCross BlueShield members will pay the pharmacy directly for the drugs prior to their hospital or doctor visit, typically a few days earlier than they do today. If the drug is less expensive through our specialty network (usually it will be), members will save on their share of the costs.

All of our specialty pharmacy partners can deliver medications anywhere in the U.S. within 24 hours. Having the drugs shipped from a specialty pharmacy isn’t a disruption compared to having them shipped from a wholesaler. These pharmacies are already shipping these drugs to providers, including in Tennessee, and we’re confident they can safely deliver them on behalf of our members.