In 2020, BlueCross BlueShield of Tennessee (BCBST) became one of the first insurers to implement a policy requiring health care providers to get provider-administered therapies from specialty pharmacies.
Typically, providers have acquired these therapies through a buy and bill model in which they buy and maintain an inventory of medications. Providers then administer the drug to the patient and bill the insurer after treatment.
Critics of this type of policy argue that it affects how providers (physician practices and infusion centers) provide care for patients and removes their flexibility in managing their business. Under this policy, the provider does not take ownership of the medication, and patients pay their copayment or coinsurance to the specialty pharmacy after the physician orders the drug. The specialty pharmacy then delivers the medication directly to the provider.
Insurers who have recently implemented similar policies include:
- Anthem Blue Cross (Anthem) is offering CVS Specialty as its designated specialty pharmacy for specialty medications administered in the office or outpatient hospital setting. To comply with Anthem’s programs related to the management of pharmacy expenses, providers are required to obtain specialty pharmacy medications administered in the office or outpatient hospital setting through CVS Specialty effective July 1, 2020. This applies to all specialty drugs covered through the Medicaid health maintenance organization (HMO) member’s medical benefits where Anthem has financial risk for the cost of specialty medications.
- Cigna, parent of PBM Express Scripts, has put out a notice stating that certain specialty medical injectables must be dispensed and their claims must be submitted by a specialty pharmacy with which Cigna has a reimbursement arrangement. Per the Specialty Medical Injectables with Reimbursement Restriction requirement, certain specialty medical injectables must be dispensed and their claims submitted by a specialty pharmacy with which Cigna has a reimbursement arrangement, unless otherwise authorized by Cigna. The reimbursement restriction list: applies when the specialty medical injectable is administered in an outpatient hospital setting; applies to specialty medical injectables covered under the customer’s medical benefit. Coverage is determined by the customer’s benefit plan; does not apply when the specialty medical injectable is administered in a provider’s office, non-hospital affiliated ambulatory infusion suite, or home setting.
- Aetna, owned by CVS Health/CVS Caremark, has introduced a requirement moving several oncology in-office therapies to a “Site of Care Management List.” Aetna supports efforts, where medically appropriate, to treat patients at non-hospital facilities or in the comfort of their home. The Site of Care policy provides criteria to determine the medical necessity of hospital outpatient administration as the site of service for identified specialty medications. This change applies to members in commercial plans who receive a renewal authorization for the below specialty medications, to continue maintenance monotherapy. This change does not apply to Medicare or Medicaid members.
- UnitedHealthcare is expanding medication sourcing requirements to apply to additional drugs that are administered in an outpatient hospital setting. To meet the requirements, outpatient hospital providers must order the medications listed from the indicated specialty pharmacies, unless otherwise authorized by UnitedHealthcare. Effective for dates of service starting June 7, 2021, to include 12 oncology supportive care drugs. Effective for dates of service starting July 1, 2021, to include 2 more specialty drugs.
Takeaway: New insurer-required white bagging policies forcing health care providers to find new options of administering provider-administered drugs