Blue Shield of California will be making some health plan changes in 2025 where new plan members will be assigned a virtual Primary Care Provider in some counties. In addition, Blue Shield will be switching to Amazon as the fulfillment center for mail order prescription medications. These changes are for the individual and family plans offered direct to consumers and through Covered California in 2025.
Accolade Care Virtual PCP
Blue Shield’s virtual Primary Care Provider (PCP) automatic assignment will be initially implemented in two regions of California for their HMO health plans. Consumers enrolling into Blue Shield’s HMO plans in Santa Barbara, Ventura, San Luis Obispo, Riverside and San Bernardino counties will be automatically assigned a PCP associated with Accolade Care beginning in September 2024. As of January 1, 2025, the virtual PCP will be available to new plan members wherever the Blue Shield HMO is offered.
Children under 18 years of age will not be assigned a virtual PCP. Blue Shield HMO plan members can change to an in-person PCP at any time. PCPs are the gateway to referrals to other specialists within the HMO (Health Maintenance Organization) health plan model. The virtual PCP through Accolade Care is a more integrated form of telemedicine. Members can schedule a virtual PCP and then complete the visit using their computer. Scheduled appointments can be possible within 24 hours of the booking.
The virtual PCP will act like a traditional office visit where patient and doctor can discuss issues, diagnose illnesses, prescribe most medications, and make referrals to specialists. Specialist visits can also be virtual from over 20 different specialists such as
- Allergy and immunology
- Cardiology
- Dermatology
- Dietary nutrition
- Endocrinology
- Gastroenterology
- Neurology
- Orthopedics
- Otolaryngology
- Psychiatry
- Urology
The virtual PCP can refer to an in-person specialist. The goal for Blue Shield’s virtual PCP implementation is to reduce wait times to see a physician and reduce costs to the plan and member. Behavioral health will also be a part of the Accolade Care virtual system as well as a health coach. PPO plan members will also be able to select an Accolade Care virtual PCP.
Amazon Pharmacy Change
Another significant change for Blue Shield’s individual and family plans will be engaging with Amazon Pharmacy for mail order deliveries. Current members will be notified that CVS Caremark Mail Service Pharmacy will be replaced with Amazon Pharmacy in 2025. Plan members will still be able to fill their prescriptions at their local pharmacies such as CVS, Walgreens, RiteAid, Save-On, and independent pharmacies. CVS Specialty will continue to provide specialty formulated prescription medications.
Why the Switch to Amazon?
Health insurance companies, and most health plans, do not manage the distribution of prescription medications. They contract with Pharmacy Benefit Managers to handle all the complicated claim’s handling at either the local neighborhood pharmacy or mail order deliveries. The pharmacy benefit landscape is huge and is dominated by a few large Pharmacy Benefit Managers owned by health insurance companies or connected to health plans.
The Pharmacy Benefit Managers are the middlemen connecting the drug company, with the pharmacies, and health plans. There have been allegations of the Pharmacy Benefit Managers negotiating contracts in their favor. For example, they have been accused of not passing along drug rebates from the manufacturer to the consumer or health plan.
Because covering the cost of prescription medications has become an increasingly larger percentage of total claims for health plans, carriers like Blue Shield are looking for ways to reduce costs. Blue Shield has determined that using the Amazon Pharmacy should save them and the plan members money. Current Blue Shield plan members will be receiving new member ID cards with updated pharmacy codes for processing prescriptions.
