X

Anthem PPO added to specialty medication policy

September 15, 2020


Anthem Blue Cross recently notified physicians that effective December 1, 2020, it will expand its specialty medication policy to also apply to its commercial PPO and EPO plans. The new PPO policy, effective for dates of service on or after December 1, 2020, mirrors policy previously implemented for Anthem’s commercial HMO and Medi-Cal managed care plans and will require that certain specialty pharmacy medications administered in the office or outpatient hospital setting be obtained exclusively through CVS Specialty pharmacy

The California Medical Association (CMA) remains concerned with the requirement to utilize CVS Specialty, citing its potential disruption of patient care and impact upon physician practices. CMA and several specialty medical associations had previously sent a joint letter to Anthem asking that it 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 who 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.

Anthem, in response to our concerns, advised it would not delay implementation of its new policy. And, although the payor had agreed to a meeting to discuss these concerns, Anthem has been unresponsive to requests for scheduling the discussion. Physicians are urged to contact CMA to report any challenges or disruptions in patient care that result from this new policy.

COVID-19
Resources

Resources for physicians and health care providers on the latest news, research and developments.

Stay Informed

Opt in to receive updates on the latest health care news, legislation, and more.

Was this page helpful?