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Anthem will not delay specialty medication policy

July 16, 2020
Area(s) of Interest: Commercial Payors 


Anthem Blue Cross, in response to the concerns of the California Medical Association (CMA) and a number of specialty medical associations, has said it will not delay implementation of its new policy requiring specialty pharmacy medications administered in the office or outpatient hospital setting be obtained exclusively through CVS Specialty pharmacy. The new policy applies to Anthem’s commercial HMO and Medi-Cal managed care products effective with July 1, 2020, dates of service where Anthem is financially at risk for the specialty medications.

Physician practices throughout the state have faced an unprecedented threat to their viability as the result of the COVID-19 pandemic. Many have been on the front lines caring for COVID-19 patients and others have had to figure out how to quickly implement telehealth to provide care to their patients and keep their doors open.

CMA and the specialty medical associations sent a joint letter to Anthem asking that they delay implementation of the specialty pharmacy policy. “As the health care system is in the early phases of reopening, physician practices remain significantly disadvantaged and unprepared to implement new policies at this juncture,” the letter said. “During the COVID-19 state of emergency, CMA has called upon all California payors to consider delaying or halting the implementation of new operational or administrative requirements, like this policy, which may significantly impact physician practices during this difficult time.“

CMA is also concerned that while Anthem first announced the policy change for its commercial HMO in April, it doesn’t appear that the payor has issued any further reminders to physicians about the July 1 effective date. Physicians that are unaware of the policy’s implementation and do not utilize CVS Specialty will, according to the notice, have their claims denied. These specialty medications are hard costs that the physician will have no way of recouping. CMA and the specialty societies are extremely concerned that implementation of this policy will cause further financial damage to practices at a time when 75% of physicians are experiencing a revenue decline of 50% or greater due to the COVID-19 pandemic.

CMA remains concerned with the potential disruption of patient care and impact upon physician practices. Although Anthem has opted not to delay implementation of the new policy, the payor has agreed to a meeting to discuss these concerns. Physicians are urged to contact CMA to report any challenges or disruptions in patient care that result from this new policy.

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