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Blue Shield of California aims to lower prescription drug prices by switching up its partnership with CVS Health's pharmacy benefit management service, a move experts say could have ripple effects across the industry.

Blue Shield is dropping most services from CVS Caremark, one of three major pharmacy benefit managers (PBMs) that help insurance companies negotiate drug prices. Instead, the nonprofit health plan will be partnering with Mark Cuban’s Cost Plus Drugs, Amazon Pharmacy and other companies to purchase and deliver drugs. The new business model is expected to begin ramping up next year and fully launch in 2025, according to The Wall Street Journal.

The shift comes as PBMs are under fire from federal regulators and Congress amid concerns that they are driving up drug prices. (PBM defenders argue that they actually lower prescription drug costs and increase access.)

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If Blue Shield's new model is able to save the insurer up to $500 million in annual drug costs as projected, it may entice more insurers or employers to follow suit or pressure PBMs to modify their business practices, according to Stacie Dusetzina, a professor of health policy at the Vanderbilt University School of Medicine.

“The announcement today from Blue Shield of California is a major step, showing a large insurer is willing to break ties with the current drug pricing and reimbursement model,” she told USA TODAY.

How Blue Shield's new model works

As of 2021, Americans on average spend more than $1,500 on prescription drugs each year, per the U.S. Centers for Medicare & Medicaid Services. More than 8% of Americans taking prescription medication have had to stop due to cost, according to data from the Centers for Disease Control and Prevention. 

While pharmaceutical companies have long been blamed for high drug costs, PBMs have come under increased scrutiny, with critics concerned that PBMs are driving up prices by favoring more expensive medications. The Federal Trade Commission last month walked back statements backing PBMs, and the Senate Finance Committee in June introduced a bipartisan bill to increase regulation on the organizations.

Blue Shield of California CEO Paul Markovich said the insurer is switching up its model because the current pharmacy system is "extremely expensive, enormously complex, completely opaque, and designed to maximize the profit of participants."

“That is why we are working with like-minded partners to create a completely new, more transparent system that gets the right drugs to the right people at the right time at a substantially lower cost," Markovich said in a statement Thursday.

A statement from Blue Shield said it aims to lower prescription costs and provide its nearly 5 million members “convenient, transparent access to medications.” Under the new business model, the insurer will be working with five companies.

• Amazon Pharmacy will deliver prescription medications.
• Mark Cuban Cost Plug Drug Company will establish a "simple, transparent, and more affordable" pricing model.
• Abarca will pay prescription drug claims.
• Prime Therapeutics – a midsize PBM owned by Blue Cross and Blue Shield health insurers– will help negotiate prices with drug manufacturers.
• CVS Caremark will continue to provide “specialty pharmacy services” for members with complex conditions.

A note led by Evercore ISI analyst Elizabeth Anderson called the announcement “an interesting change in the PBM landscape.”  

“Many in the industry will likely be watching this situation closely as managing the five partnerships could prove tricky,” Anderson said in the note. But if Blue Shield’s move is successful, “we could see additional regionals move more in a similar direction.”

What CVS Health says

The Wall Street Journal reports that some experts are worried Blue Shield will struggle to match the discounts negotiated by PBMs. 

“The decision to carve out so many different offerings carries potential execution risk that could result in a less coordinated offering for patients,” J.P. Morgan analyst Lisa Gill said in a research note.

The stock price of various PBM companies dipped Thursday, but CVS maintains that Blue Shield’s decision will have no impact on its 2023 guidance.

CVS Health spokesperson Ethan Slavin highlighted that the company will continue to provide specialty pharmacy services, which represent over half of pharmacy benefit spend in the marketplace.

“Fragmentation in the health care industry is one of the primary reasons health care remains too complex and expensive,” Slavin said. “We remain confident in the value we provide our customers and that our integrated solutions will continue to resonate in the marketplace.”