Prime Therapeutics Questions and Answers for BCBSNC Employer Groups
Last week, investment bank Morgan Stanley issued a “Healthcare Services & Distribution” report that makes reference to a potential change in Blue Cross and Blue Shield of North Carolina’s (BCBSNC) Pharmacy Benefits Management relationship. Because this mention could generate questions from our customers, we want to share some information with you about this. As part of our effort to reduce costs for our company and our customers, BCBSNC is in negotiations to change our pharmacy benefits management vendor. Assuming that final negotiations are concluded successfully and we receive regulatory approval, Prime Therapeutics would administer pharmacy benefits for our commercial customers whose pharmacy benefits we handle.
We hope this change will take place beginning April 1, 2012. This change would result in lower pharmacy costs for BCBSNC and our group customers, and would provide more flexibility regarding services and programs.
Please refer to the questions and answers below for more information. Questions and Answers for BCBSNC Employers and Members
Who is Prime Therapeutics?
Prime Therapeutics (Prime) is a thought leader in the pharmacy benefit management (PBM) industry. Its mission is to provide the highest quality care and service for members while focusing on delivering the lowest cost of care and empowering clients to make informed decisions in health care management. Prime is owned by 9 entities, representing 12 BCBS plans, and is the fourth largest PBM in the industry.
What is Prime’s ownership structure?
Prime is a privately-held company owned jointly by 12 Blue Cross and Blue Shield (BCBS)health plans:
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???? Blue Cross and Blue Shield of Florida
???? Blue Cross and Blue Shield of Illinois
???? Blue Cross and Blue Shield of Kansas
???? Blue Cross and Blue Shield of Minnesota
???? Blue Cross and Blue Shield of Montana
???? Blue Cross and Blue Shield of Nebraska
???? Blue Cross and Blue Shield of New Mexico
???? Blue Cross and Blue Shield of North Dakota
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Through its private ownership structure, Prime is able to focus on BCBS stakeholder value, not stockholder value. Prime offers a proven, strategic partnership that supports its clients’ overall health care goals. BCBSNC would be part-owner of the company.
Why is BCBSNC looking to make this change?
BCBSNC decided to explore changing pharmacy benefits managers (PBMs) for a number of reasons. Most importantly, we want to secure the most competitive pricing possible, which means we would be better able to control pharmacy claims expense.
Prime offers the economies of scale of a national provider with the flexibility, customization and quality service of an in-house solution. As a leading PBM owned by Blue Cross and Blue Shield plans, Prime is uniquely able to meet our high standards, while at the same time leveraging best practices. As a result, Prime consistently delivers the best pharmacy trend of the major PBM competitors, and outperforms them in customer satisfaction.
How much will I save?
One important reason that BCBSNC decided to contract with Prime Therapeutics was to secure better pharmacy discount pricing. Prime works with clients to identify factors driving their pharmacy trend and then implements various approaches to lower pharmacy costs. These include:
• Low net-cost approach. Prime uses a low net-cost approach that is applied to formulary development, benefit design, manufacturer contracts, and network reimbursement. Using this approach, Prime has helped health plan clients successfully decrease overall per member per month costs.
• Maximum allowable cost (MAC) program (generic drug pricing). Prime believes its MAC program to be the most clinically comprehensive and competitive in the industry
• Driving employees to lower-cost drugs. Driving utilization to lower-cost products is a key to managing costs. Prime has several programs to move utilization to lowercost brand and generic products. Actual member or group level savings will depend on a number of factors including specific utilization patterns.
Does this have any impact on me now?
No. The target date for moving to Prime is April 1, 2012, pending completion of final negotiations and regulatory approval. Therefore, there are no changes for members at this time.
Why are you targeting a 4/1 implementation date?
The tentative 4/1/2012 implementation date was chosen to ensure that appropriate quality and service associated with planned annual renewals is maintained. Implementing off-cycle also ensures minimal disruption to membership during transition.
Will there be any cost to the group for this transition?
No. There are no costs to BCBSNC members or groups associated with the change from Medco to Prime Therapeutics.
Are my benefits changing?
Prime Therapeutics will be able to administer your pharmacy benefits without making significant benefit changes. Any changes to your pharmacy benefit will be positive additions driving to lowest net costs for you and your membership. The change from Medco to Prime Therapeutics will be nearly transparent to BCBSNC members.
How will my deductibles, accumulators, out of packet maximums transfer?
BCBSNC will work with Prime to ensure that all records are transferred to the Prime claims system appropriately. When the change from Medco to Prime Therapeutics becomes effective, the change will not affect deductibles, accumulators or out of pocket maximums.
Will I need to change pharmacies?
While Blue Cross and Blue Shield of North Carolina reviews its retail pharmacy network options regularly to ensure the best pricing for its clients and members, there are no plans to change the pharmacy network at this time. The process for filling your prescription at a retail pharmacy would not change. Bring your prescription and member identification (ID) card to a pharmacy in your pharmacy network. The pharmacist will send your prescription electronically to Prime to confirm your benefit plan and ensure the correct prescription price.
What prescription mail service option is offered by Prime? How will mail order prescriptions transfer?
PrimeMail® is Prime’s prescription mail service. PrimeMail makes transferring prescriptions, ordering new prescriptions and ordering refills safe, fast and easy. In addition to easy ordering, PrimeMail members have access to member service agents 24-hours a day, seven days a week. PrimeMail customers can also use the member website to order refills, track their prescription history and find drug information. With PrimeMail, prescription medications are confirmed for accuracy and quality by registered pharmacists and delivered to your door in safe, plain-labeled packaging. When the transition occurs, if you have a prescription with Medco mail service, and there are open refills, that information will automatically be transferred to Prime and your refills will be delivered to you without interruption. You won’t have to wait for your important medications.
Will Prior Authorization (PA) files transfer?
Yes. During the integration, Prime will work with Medco to transfer historical PA files as part of the overall transition of member records. Members will not have to reestablish PA status.
Will this affect BCBSNC’s specialty pharmacy program?
No. There will be no change to the specialty pharmacy network launched on July 1st.
The information in this article was taken from a Press Release from Blue Cross Blue Shield of North Carolina on August 1, 2011.
For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our professional agents. Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC). You may qualify for a 15% healthy lifestyle discount if you are in excellent health. Call us for details.