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Why affordable provider-administered drugs for all Tennesseans must be a priority

Originally published in The Tennessean, December 2021

All of us have used medication to treat an illness. Many of us take medication on an ongoing basis to help manage a medical condition. But for a relatively small number of us, those medications require a more complicated treatment process than taking a pill.

Provider-administered specialty drugs are medications that a doctor or nurse may give a patient  in the office, like a shot or an IV infusion. Many of these drugs offer huge potential, treating conditions previously thought untreatable — but traditionally, they’ve been extremely expensive. And costs for these drugs continue to rise.

For years, BlueCross has worked to lower the costs of these drugs for our members. In 2022, we’re making these drugs more affordable for even more of them.

A plan in action

Taking a step back, Tennessee businesses want to cover these drugs for their employees and asked BlueCross to help bring the prices down. That’s especially true for our “self-funded” employer groups — those who pay for their employees’ health care themselves but use BlueCross networks and services. Based on their input, we knew we had to act.

In 2019 alone, our customers paid more than $1.6 billion for specialty drugs. Provider-administered drugs accounted for more than half of those costs — more than $975 million.

At BlueCross, we’re committed to delivering cost savings. During these last two years of uncertainty, these savings are more important than ever. And for our members who rely upon these drugs, we knew we had to prevent as much disruption as possible. 

Lengthy consultations with these customers and our provider partners followed. We then implemented our Advanced Specialty Benefit Management (ASBM) program on Jan. 1, 2020 for many self-funded groups. 

Instead of members paying the health care provider who administers their drug, they use our specialty pharmacy network and pay the pharmacy that sends the drug directly to their provider. The resulting savings come from our negotiations with the pharmacies in the network. These savings go directly to self-funded groups and their employees — not BlueCross. 

How specialty pharmacies work

An example I often share is Opdivo, a provider-administered drug used to treat cancer. If a provider buys from a wholesaler and bills BlueCross, the average cost per treatment for a member is $3,341. But if a provider orders from a specialty pharmacy, the average charge for a member is$2,971. That savings of $370 per treatment makes a significant difference for our affected members.

We didn’t want to change what drugs we cover, since many are life-changing or even lifesaving. And we didn’t want our members to change where they got care, as we value the relationships they have with their providers.

We took these providers’ concerns to heart and phased in our changes with a six-month transition to make it easier for them and so we could make adjustments based on their feedback. We’ve heard several misperceptions, like that we’d require members to handle the drugs themselves or that specialty pharmacies aren’t equipped to properly deliver the drugs. These aren’t true.

Based on the results we’ve seen, this benefit maximizes efficiency and savings while assuring member comfort and ease during treatment.  And so far, our efforts have saved businesses 14% on average on provider-administered medications.

That’s why we’re now moving forward, expanding it to even more members. As of Jan 1. 2022, all commercial fully insured plans, both group and Marketplace, are eligible.

We believe our program will continue to provide safe, convenient access to these important medications while saving money for employers and members.

And making drugs affordable for all who need them is something no one can argue with.

About Natalie Tate, PharmD, Vice President of Pharmacy

A photo of the authorDr. Tate oversees all aspects of the pharmacy management program and provides strategic direction for our teams charged with helping BlueCross members improve their health outcomes.

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