Advocate+™ Pharmacy Match: BCBSKS’ new specialty pharmacy program

Starting Jan. 1, 2027, a new specialty pharmacy program uses competition to drive better pricing and gives members one-on-one support when they need it most.

Specialty medications treat some of the most complex conditions your employees may face. They're also one of the biggest cost pressures on your health plan. Specialty drugs already make up more than half of total pharmacy spend, and that amount is expected to keep growing.

Advocate+ Pharmacy Match expands the Blue Cross and Blue Shield of Kansas (BCBSKS) specialty pharmacy network creating more savings for one of the biggest cost drivers for health plans. The program matches each specialty prescription to a well-qualified, in-network pharmacy based on price, experience and care. Additionally, members are connected to a care specialist to help provide support and answer questions along the way.

Who Pharmacy Match applies to

Pharmacy Match applies only to groups with Mandated Designated Specialty Pharmacy (MDSP). It takes effect for all of these groups on Jan. 1, 2027, regardless of renewal date.

Many BCBSKS plans include a mandated designated specialty pharmacy provision as a part of their benefit plan design. It means that for specialty medications to be covered under the pharmacy benefit, they must be filled at a pharmacy designated by the plan — not at just any pharmacy. This applies only to specialty drugs, which are typically delivered by mail. Retail pharmacy coverage for everyday prescriptions is not affected.

Competition is what drives savings

Many specialty pharmacy programs steer prescriptions to a single preferred pharmacy or a narrow network of pharmacies. Some programs even steer prescriptions to pharmacies owned by or affiliated with the pharmacy benefit manager (PBM).

Pharmacy Match works differently. It expands the specialty pharmacy network and uses near-real-time competitive pricing to find the best fit for each prescription.

For commercial business, Pharmacy Match is estimated to save $1.96 to $3.26 per member per month. Results for individual groups will vary.

Support that makes a hard time easier

Getting a diagnosis that calls for a specialty drug can be overwhelming. Sometimes patients can wait as long as seven to 10 days before hearing from a pharmacy. During that time, they often don't know how specialty pharmacies work, what it will cost or who will fill it.

Advocate+ Care Specialists step in early. Care Specialists call members early in the process and become a resource for members during what can be a stressful time. Here's what they do:

• Guide members through next steps. They explain which pharmacy will fill the medication and what to expect.
• Answer questions. That includes requirements such as prior authorization. 
• Connect members with financial help. Care Specialists search a database of more than 7,000 assistance programs, and automated processes can save members up to 60% of their time per application.
• Keep an eye on prescriptions. They track prescription status to make sure members get good service from their pharmacy.

What employees already taking specialty drugs can expect

Members on plans with MDSP who already take a specialty medication will get a letter in January explaining the Pharmacy Match program. If a member is matched with a new pharmacy, a Care Specialist will call to explain the change, coordinate the handoff and answer questions. Changes for members currently taking a specialty medication would not go into effect until February.

The member's medication itself doesn't change. They receive the same drug their provider prescribed, and their dosage and treatment plan stay the same.

How you can help your employees

Let employees know a change is coming, especially if you know some of them use specialty medications. Encourage them to watch for the January letter and take the Care Specialist's call.

Employees can reach a Care Specialist at 833-950-3858, Monday through Friday from 7 a.m. to 9 p.m. Central time.

Answers to common questions

Does Pharmacy Match change my plan's benefits?
No. Some members may move to a different pharmacy, but their benefits stay the same.

If the member’s prescription is currently being serviced through an IntegratedRx^® pharmacy (a pharmacy integrated with the member’s health system or provider), will it stay at the integrated pharmacy?
Yes, if a member is currently filling prescriptions through a IntegratedRx pharmacy, they will continue to receive fills through that pharmacy.

What if a member is running out of medication during the transition?
A one-time override is available while the match is being finalized. Members should contact their Care Specialist for help.

What if a member takes more than one specialty drug?
Pharmacy Match tries to use one pharmacy for all of a member's specialty drugs. In some cases, members may need to use more than one.

Can Advocate+ assist members with their pharmacy or medical benefits?
No. Advocate+ is not a replacement for their current pharmacy and medical benefit services. Members will need to call the number on the back of their ID card if they have questions regarding their benefit or claims.