Broker Update

Optimizing our retail pharmacy network

Impacts: IFP, Medicare, Commercial Group members

Beginning in 2025, Navitus will manage our retail pharmacy network. As we optimize this network, some independent pharmacies in the current CVS Pharmacy® retail network may not meet the stricter retail network participation criteria, or may simply choose not to contract with Navitus.

Some reductions to the pharmacy network are unrelated to our transition to a new network manager and are a result of market dynamics that have seen an increase in the number of retail pharmacy locations closing across the country.

Regardless of the reason, members impacted by the pharmacy network change for 2025 will be notified in advance and provided guidance for transferring prescriptions to an in-network option. For members with limited retail pharmacy options, Amazon Pharmacy home delivery can be an option for both convenience and cost.

Our Pharmacy Network page will continue to be updated with relevant information

New member ID cards

Impacts: IFP, Medicare, Commercial Group members

Beginning with October 1 plan effective dates, members received new ID cards with updated pharmacy information. An insert was included with instructions for members to bring their new ID card to the pharmacy on their next visit. Updated ID cards can be accessed through the member's online myblueshield account and via the Blue Shield mobile app so that they always have the most current version.

Updates to the ID card will mostly go unnoticed by the member, such as reference numbers for pharmacists. These changes, however, are essential for processing member prescription claims accurately beginning January 1, 2025.

Biosimilar strategy | Humira

Impacts: IFP, Medicare, Commercial Group members

Biologics are powerful drugs made from living organisms used to treat a range of complex conditions, from autoimmune disorders to cancer. A biosimilar is an alternative version of a biologic nearly identical in chemical structure, clinical function, and effectiveness. Just as you might take a generic version of a brand name prescription drug – think, ibuprofen instead of Advil – a doctor could prescribe a biosimilar in place of a biologic to treat a complex medical condition.

Matthew Gibbs, Blue Shield’s VP for Pharmacy Transformation, explains biosimilars and why they’re essential to bringing down pharmacy costs overall in this article and video.

Humira: Demonstrating the potential cost-saving impact of biosimilars, Blue Shield announced earlier this fall a collaboration with Fresenius Kabi and Evio Pharmacy Solutions to purchase FDA-approved Humira biosimilar (adalimumab-aacf) for $525 per monthly dose, compared to the market reported net price of Humira at $2,100.

Humira will no longer be included in our formulary beginning January 2025. IFP and/or Commercial members with an existing prescription for Humira are being notified of the change and encouraged to switch to the biosimilar but are not required to do so. Commercial members switching to the biosimilar (adalimumab-aacf) will have $0 cost share. If they continue with brand name Humira, their Tier 4 prescription drug benefit cost share (up to the max copay, $250 for most plans) will continue according to their plan benefits in 2025.

For commercial members newly prescribed Humira in 2025, their provider must request a medical exception necessity to the formulary coverage. If the exception is APPROVED, the Tier 4 cost share up to the max copay ($250 for most plans) could apply. If the exception request is not approved and the member wants to take Humira, they will be responsible for the full cost of Humira.

For Medicare plan members in 2025, Blue Shield is pursuing a biosimilar-only strategy with Hadlima as the formulary biosimilar for Humira. Regulations, specialty network, and pricing differ between Commercial and Medicare lines of business and these differences factored into the decision to have separate biosimilar strategies by line of business. Both Hadlima, the biosimilar selected for Medicare formularies and adalimumab-aacf, the biosimilar selected for the Commercial formularies, are equally safe and effective.

Member pays the difference

Impacts: Large group members only

“Member pays the difference” is intended to maximize savings with generic and preferred alternative drugs, when available, delivering overall cost savings for members and plan sponsors. Members still have the flexibility to choose a brand-name drug if desired. However, when a lower-cost alternative is available, members will pay the difference. The above article, describing biosimilar alternatives to Humira, is one example of how members may benefit when this is implemented.

If a member or prescriber selects a covered brand-name drug when a generic equivalent or preferred biosimilar drug is available, the member will pay the applicable tier copayment or coinsurance of the brand-name drug, plus the difference in cost between the brand-name drug and generic equivalent or preferred biosimilar drug.

Cost transparency is essential for members to make informed decisions about their prescription drug choices. Enhancements to our pharmacy digital experience enable members, and their providers, to easily see options including generics and biosimilars, as well as dispensing locations and alternatives (e.g., home delivery).

As is standard business practice, and required, members impacted by this benefit structure change will be mailed notifications. “Member pays the difference” benefit descriptions and disclaimers are also included in plan documents for 2025 (Summary of Benefits, Evidence of Coverage, etc.).

Amazon Pharmacy home delivery

Impacts: IFP, Medicare, Commercial Group members

Prescription drug home delivery will shift from CVS Caremark Mail Service Pharmacy to Amazon Pharmacy on January 1, 2025. CVS Pharmacy retail locations will remain in network and CVS Specialty® will continue to provide specialty pharmacy services.

Members who currently use the CVS Caremark Mail Service Pharmacy for prescription home delivery received communications from Blue Shield in October introducing Amazon Pharmacy as our new pharmacy home delivery vendor, along with information on getting started with using Amazon Pharmacy home delivery services: Commercial | Medicare

After January 1, 2025, members who have not yet taken action will receive a communication from Amazon Pharmacy stating their prescription is ready to be filled and must create their Amazon Pharmacy profile to complete their order and avoid interruptions in home delivery.

Controlled substances

Amazon Pharmacy does not fulfill Class II controlled substances. Members who have a Class II prescription being fulfilled by CVS Caremark Mail Service Pharmacy will be provided instruction on how to transfer their prescription to a retail pharmacy.

Amazon Pharmacy does fulfill Class III, IV, and V controlled substances, however, these require a new prescription sent from providers directly to Amazon Pharmacy. A communication campaign for providers regarding this topic is being developed by Blue Shield’s Provider Communications team and is expected to have been launched at the time of this newsletter’s publication.

Prescription coverage for weight loss drugs

Impacts: IFP, Small Business group members

Effective January 1, 2025, Blue Shield of California will no longer cover drugs for weight loss, unless medically necessary for the treatment of Class III obesity (also known as morbid obesity). Members can find more information about weight loss drug coverage in their Evidence of Coverage or by contacting Customer Service at the number on their member ID card. This benefit change will apply to the following prescription drugs:

Coverage for the treatment of Class III obesity also requires member participation in a comprehensive weight loss program (including a reduced calorie diet, physical activity, and behavior therapy) for a reasonable period of time prior to and while they are using the weight loss drug.

Starting in 2025, upon plan renewal, members who are requesting weight loss drugs must meet new prior authorization requirements for approval. Members who do not meet the new coverage requirements will be responsible for the full cost of the drug.

Members who are using any of the weight loss drugs above for reasons other than the treatment of Class III obesity will be notified of the changes to their benefit.

Members who currently meet the new requirements will be able to continue to fill their drug until the end of their authorized period without interruption.

• There is no change to coverage for the use of GLP-1’s for the treatment of Type 2 diabetes.
• These coverage parameters outlined above already apply to Large Group plans.