New Strategies to Manage Specialty Drugs

Managing costs for prescription drug benefits is one way BlueChoice HealthPlan works to help our employer groups and members. This notice provides an update on our 2016 strategy for managing specialty drugs, a major factor in the trend of rising drug costs. These changes apply to BlueChoice^® fully insured, self-insured, Affordable Care Act (ACA)/Exchange lines of business.
 
BlueChoice has a four-part strategy for managing specialty drug benefits. We are already implementing two parts. One requires providers to include certain codes that help improve tracking of drug claims and billing. The other involves encouraging members to use alternative, more cost-effective sites for receiving specialty drugs when possible (for example, at home or a doctor’s office rather than at an out-patient hospital facility).
 
Starting June 1, BlueChoice will implement the other two specialty drug requirements:

• Self-administered specialty drugs. Certain self-administered drugs will only be covered under the pharmacy benefit. Previously, some had also been covered under the medical benefit.  BlueChoice requires our members to use CVS/specialty to fill prescriptions for specialty drugs. CVS/specialty is a division of CVS Health, an independent company that provides specialty pharmacy services on behalf of BlueChoice. Some specialties will be exempt from this, including hematologists, oncologists, nephrologists and rheumatologists.
• Prior authorization: Certain specialty drugs billed under the medical benefit require prior authorization. CVS/caremark will now assist in review of these prior authorizations using Novologix, an industry-leading prior authorization software system. Additional drugs will be added to this list. This means  members who didn’t need prior authorization for these drugs will now need one. However, members taking drugs that require a prior authorization for the first time under the medical benefit will have until July 1 to meet the requirement.

Some background: Doctors prescribe specialty drugs to treat certain serious, chronic conditions. Relatively few of our members use these medications — about 1 percent or fewer. But these medications can be extremely expensive, accounting for more than 30 percent of all prescription drug spending. 
 
Our strategy for managing specialty drugs aims to:

• Manage and limit these costs, when possible.
• Make sure specialty drugs are prescribed appropriately for members who need them.
• Look toward the future with smart programs to monitor use of these drugs. According to industry estimates, specialty drug costs could total $400 billion by 2020, representing more than 9 percent of all spending for health care.

Communications Plan: BlueChoice will notify groups about these changes. We will also send letters to members affected by these changes at the beginning of May. 
 
For details, please contact your BlueChoice representative.