What Does Pharmacy Care Reimagined Mean for Blue Shield Members?

by Matt Gibbs, chief pharmacy officer, Blue Shield of California

Seamless home delivery is just one way Blue Shield is improving the pharmacy care experience

At Blue Shield of California, we strive to ensure all Californians have access to high-quality health care at an affordable price. Delivering affordable, transparent pharmacy care is a primary component of that mission.

Pharmacy is often the most frequent touchpoint within our healthcare journey. Yet, for many of us, the experience is costly, opaque and hard to navigate. That’s why Blue Shield of California set out to reimagine the prescription drug experience with the goal of building a pharmacy ecosystem that prioritizes better value for our members.

Much of our initial work has focused on challenging the traditional supply-chain model, transforming how different players in this complex ecosystem work together — all in the service of our members. From rethinking these intricate models to working with various collaborators to lower drug costs, we’re laying the groundwork now for a more sustainable and patient-forward system.

What’s happening behind the scenes?

Matt Gibbs, Chief Pharmacy Officer

Reimagining pharmacy care requires addressing the structural issues that have long plagued our healthcare system. One of the most significant shifts is breaking away from the traditional pharmacy benefit manager (PBM) model — a model that has given rise to three major PBMs, which together control 80% of the market.

While their mandate is to lower drug costs for employers and health plans, PBMs instead have operated as opaque intermediaries within the pharmacy supply chain. They profit from complex pricing structures that often increase the cost of drugs for patients. These conglomerates draw negative attention for practices like prioritizing medications that deliver the most profit to themselves, tacking on hidden fees, and pocketing part of the discounts they negotiate with drug manufacturers and retail pharmacies — savings that should be passed on to consumers. (Read more about how PBMs affect your health care here.)

This model doesn’t work for anyone but PBMs. It doesn’t work for health plans or employers; it’s not good for drug manufacturers or pharmacies. Most importantly, it’s bad for consumers.

Because of this, Blue Shield set out to unbundle the services traditionally handled by PBMs and instead build a new pharmacy service model that allows Blue Shield to provide members and employers with accurate drug pricing for truly informed decisions.

You might already be seeing these changes. Last year, for example, we announced a collaboration with drug manufacturer Fresenius Kabi and Evio Pharmacy Solutions to purchase a Humira biosimilar for a transparent net price of $525 per monthly dose — far less than the approximately $2,100 monthly cost previously associated with Humira when traditional PBMs are involved. Now, most Blue Shield members can access this biosimilar option at a fraction of the cost.

As part of that work, we’re leveraging state-of-the-art technology to make the pharmacy care experience much more convenient and streamline how prescription drugs are delivered to our members. Here’s what you can expect in the coming year.

What’s new for Blue Shield members in 2025?

While most of the changes happening behind the scenes at Blue Shield of California are part of a larger strategy to transform the industry, there are some key improvements to the pharmacy care experience you’re likely to notice:

• Seamless home delivery: Through our partnership with Amazon Pharmacy, Blue Shield members can opt in to enjoy the convenience of 30-day or 90-day supplies of prescription medications delivered directly to your door.
• An intuitive digital experience: Redesigned web and mobile platforms will allow you to navigate your pharmacy benefits with ease, including through single sign-on with Amazon Pharmacy Home Delivery.
• Access to lower-cost medications: We are equipping our members with new digital tools to be able to easily find in-network retail pharmacies, compare drug prices, receive notifications for lower-cost medication alternatives and monitor expenses. Read more about how we’re building a transparent pharmacy model here.

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Throughout the year, you’ll see more innovations that improve transparency, convenience and affordability. Every step we take is focused on making sure our members have the best possible pharmacy care experience — at the best possible prices.

Building for the future

Reimagining this process is no small task. It takes significant work to make even minor changes in our colossal healthcare system, but we’re committed to doing the hard work now to deliver lasting results — and helping our members navigate the transition as we move toward a fairer, more transparent system.

That won’t always mean lower prices for each specific prescription drug, at least not immediately, as we continue to advance our new model. The low prices members paid for certain medications in the past were artificial, driven by PBM pricing tactics rather than actual costs. This is just one of the many tools that PBMs have used for years to steer members toward specific pharmacies that benefit them financially. Increased transparency allows members and employers to gain insight into the true cost of their medications and make informed decisions in their best interest. While most members will see savings under this model, others may experience price increases on specific drugs. A medication that once cost $1-2, for example, may now be $10-15. The reality is, that medication was never truly $1 to begin with.

Achieving this systemwide transformation for our members and healthcare consumers everywhere requires more than just our efforts here in California. It calls for bold action from stakeholders across the healthcare industry. Employers, health plans, pharmacy providers, policymakers and others must be willing to examine our current, overly complex prescription drug system and be courageous enough to try something new.

At Blue Shield of California, we’re proud to be at the forefront of this movement. We’re excited to continue this journey with you as we transform pharmacy care for the better.