The Oakland-based insurer made headlines last year when it said it would unbundle its pharmacy benefits, including limiting a years-long partnership with CVS Caremark. Blue Shield opted to use Mark Cuban Cost Plus Drug Co. and Amazon Pharmacy over the traditional PBM.
In October, Blue Shield of California said it reached a deal with drug manufacturer Fresenius Kabi to purchase its Humira biosimilar straight from the manufacturer. The deal was facilitated by Evio Pharmacy Solutions, a company backed by several Blue Cross Blue Shield plans.
Matt Gibbs, PharmD, pharmacy transformation leader at Blue Shield of California, told Becker’s Blue Shield of California is the first plan to broker a direct biosimilar purchase deal through Evio, but he hopes it is not the last.
“We want everybody to start thinking about doing it this way. It’s bigger than us, and we’re excited to get it out there and make it available to our members,” Dr. Gibbs said.
Blue Shield expects the move to reduce costs for members and improve medication adherence for Humira, the drug the insurer spends the most money on. Blue Shield will pay Fresenius Kabi $525 per dose of its biosimilar, compared to the typical net price of $2,100 for Humira.
Dr. Gibbs said Blue Shield plans to use a similar approach for other biosimilars in the future.
The first Humira biosimilars hit the market in January 2023, but uptake among payers was slow at first. In 2025, all Express Scripts, CVS Caremark and Optum Rx, the three largest PBMs, will prefer biosimilars over Humira in their formularies.
“Payers have to start showing that they believe in this market and not riding the rebate train forever,” Dr. Gibbs said. “When you do that, there’s no incentive to create lower cost options.”
Blue Shield of California is preparing to go live with much of its pharmacy care reimagined initiative in 2025.
Blue Shield is betting big on the transformation. In 2023, CEO Paul Markovich told Becker’s the company would “push everybody else to probably adopt something similar,” with its pharmacy benefit strategy.
Dr. Gibbs said the model has drawn a ton of interest from other organizations and drug manufacturers.
“Change is not easy. These are things that are bucking the industry trend, and can make some of our competitors or other organizations uncomfortable, but we know it’s the right thing to do,” he said.
Dr. Gibbs joined Blue Shield of California earlier this year to lead the company’s pharmacy transformation initiatives.
Pharmacy spending accounts for up to 40% of costs at some health plans, Dr. Gibbs said, and could outpace medical spending. With costs on the rise, Dr. Gibbs expects to see pharmacists take on larger leadership roles at payers, and have a role in overall corporate strategy, not just the pharmacy department.
“I’m hopeful there will be a pharmacy transformation leader at every major health plan in this country. It’s a needed investment,” he said.
