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At BlueCross, we’re committed to delivering cost savings for members. And we know that during these last two years of uncertainty, those savings are more important than ever.

On Jan. 1, 2020, we changed the way some members get certain provider-administered specialty drugs, or medications that a doctor or nurse may give a patient in the office, like a shot or an IV infusion.

Our Advanced Specialty Benefit Management (ASBM) program initially applied to many self-funded employer groups who pay for their employees’ health care themselves but use BlueCross networks and services. And we’ve already seen significant cost savings for these members and groups.

• Outside of the program, these drugs would have cost more than $114 million.
• Acquired through the specialty pharmacy network, they’ve cost around $98 million.
• That amounts to more than $16 million in savings.
• The ASBM program saves 14% on average on provider-administered medications.

“Instead of paying the provider who administers this drug, members use our specialty pharmacy network and pay the pharmacy that sends this drug directly to their provider,” says Natalie Tate, PharmD, vice president of pharmacy at BlueCross. “The resulting cost savings come from what we negotiate with the specialty pharmacies in the network. The benefit maximizes efficiency and savings while assuring member comfort and ease during treatment.”

Based on its success, on Jan. 1, 2022, the program will expand to include all commercial fully insured plans,  both group and Marketplace.

Cost consideration

It’s important to understand why these provider-administered drugs are so expensive.

Many offer huge potential, treating conditions previously thought untreatable, yet they’re administered to a relatively small number of people overall. Research and development at the pharmaceutical companies that produce these drugs takes years, resulting in high costs. And there are now more provider-administered specialty drugs in development than any other kind of drug.

From the outset of examining how we could help manage these costs, we had two priorities to ensure we adhered to our mission of peace of mind through better health.

• We didn’t want to change what drugs we cover, since many of them are life-changing or even lifesaving.
• We didn’t want to ask members to change where they got care. We know how much our members value the relationships they have with their health care providers — and we do, as well.

How the program works

After communication from a provider’s office, a specialty pharmacy in our network will ship all provider-administered specialty drugs directly to the provider within 24 hours of order.  The biggest change for members is they now pay the pharmacy before the drug is shipped — typically a few days earlier than they would normally pay — instead of paying the provider at the time of service.

An example we often share is the process of getting Remicade, a provider-administered drug that treats rheumatoid arthritis.

Before this program launched, a provider could buy Remicade from a specialty pharmacy in our network and have a patient’s dose delivered to the provider’s office or treatment facility, or they could buy it in bulk from a wholesaler.

Because many providers preferred buying in bulk and then billing BlueCross and the member for each dose, we’ve also worked with our in-state providers to give them an option to maintain their operational processes, while still providing savings to our groups and members.  

The beauty of this program is that it lets members continue using their network provider of choice — including providers who offer home infusion. The program only applies to specialty drugs administered in a provider’s office or facility, not self-administered specialty drugs delivered to members’ homes.

Ensuring reliable delivery

Due to complexity of many of these medical conditions, many of these drugs must be administered on an exact schedule. We’ve listened to concerns from employers, providers and members about timeliness of delivery.

The specialty pharmacy will ship the drugs directly to the member’s provider within 24 hours of their scheduled appointment.

We’re not asking the member to receive these drugs at home or be responsible for handling the medication.

“The pharmacy will call the member to answer any questions they may have about the prescription and arrange payment,” Dr. Tate says. “They’ll also call both the member and their provider close to the scheduled administration to confirm the date of administration, dosing changes, their health status, as well as any other possible changes to treatment plan. Nothing is shipped before confirming these details.”

The specialty pharmacies in our network have contracts that hold them accountable for proper preparation and delivery of these drugs, including factors like temperature control. These pharmacies are experts in the storage, preparation, and delivery of specialty medications,  and offer 24/7 access to pharmacists and other clinicians who specialize in the conditions associated with prescribed medications.

We’ve already notified affected members of this change — a change that won’t affect their existing prior authorizations or manufacturers’ copay assistance programs. And as we did in 2019 ahead of the launch of this program for our self-funded groups, we’re working with providers to ensure a smooth transition for our fully insured members.

As we enter 2022, BlueCross will continue finding ways to reduce treatment costs for our members — and work to expand this program to as many of them as possible.