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CVS pharmacy prescriptions no longer covered for many Blue Cross Blue Shield of Montana members

January 16, 2017 GMT

About a third of the members in Montana’s largest private health insurance company can no longer get their prescriptions covered at one of the world’s largest pharmacy chains.

Since Jan. 1, CVS pharmacies haven’t been included in Blue Cross Blue Shield of Montana’s standard pharmacy network after price reimbursement negotiations for certain drugs failed in 2016.

“Our main priority is the affordability of care for our members,” said John Doran, BCBS spokesman. “We are trying to do everything possible to minimize charges, and to do that we have to get competitive reimbursement rates. CVS requested additional higher reimbursement rates for generic prescriptions compared to other pharmacies we work with.”

The standard BCBS coverage network, which is administered by Prime Therapeutics, includes fully insured groups, small groups and individual retail markets, but not all self-funded commercial groups.

Mike DeAngelis, senior director of corporate communications for CVS Health, noted in a statement emailed to the Gazette that the decision by BCBS doesn’t affect all of the insurance company’s members, only plans for smaller groups or plans that were enrolled in through the Health Insurance Marketplace established by the Affordable Care Act.

“It was not our desire or decision to be excluded from this preferred pharmacy network,” he said.

The decision does not include all BCBS members insured through self-funded plans, which allow individual companies to choose some of the networks in which they participate. However, not all of those members may be able to use CVS, depending on their company plan.

CVS operates more than 9,600 pharmacy locations in the U.S., Puerto Rico and Brazil, including 16 scattered throughout eight Montana cities.

According to BCBS, about 100,000 of its members in Montana have filled at least one prescription at a CVS location over the years.

The decision means that, using 2016 enrollment numbers, 27,000 fully-insured members in group plans of 51 people or more, 40,000 members in small group plans and 54,000 people purchasing individual plans won’t be able to fill prescriptions at CVS using BCBS insurance.

Within that group, 15,600 members actually filled prescriptions at CVS pharmacies in 2016, according to Blue Cross figures.

There are about 300,000 total members served by BCBS Montana.

Doran said that the insurance company analyzes all of its provider networks on a regular basis and that the pharmacy company’s request for generic drug reimbursement rates was simply higher than other pharmacies.

That led to BCBS’ decision to not renew the contract with CVS, effectively removing it from its pharmacy network.

DeAngelis said that, in addition to the commercial self-funded plans CVS still accepts BCBS Montana Medicare Part D plans and will help others figure out if they’re covered as well.

“If a CVS Pharmacy patient is unsure whether their BCBS coverage is still accepted by our 16 pharmacies in Montana, they can bring their prescription to their local CVS and we will assist them,” he said.

Members do still have access to more than 55,000 in-network pharmacies nationwide, including ones at chains such as Walgreens, Walmart, Albertsons, Osco Drug, Safeway, Shopko and Costco, as well as a number of independent pharmacies.

The insurance company began notifying its members of the change in November, and sent additional letters to anyone who filled a prescription at CVS in the last months of 2016.

“There are so many options in Montana that do fill these generic prescriptions at a better price, that we feel there are still plenty of options for our customers,” Doran said.