Apr 07, 2025
While Blue Shield's new pharmacy model is designed to drive down overall costs, some members may be experiencing cost increases for their individual prescription medications since 1/1/2025.
There are several possible reasons why this may be the case, including:
- At the start of each year members are in their deductible period and therefore prescription costs will be higher than at the end of the calendar year. While this may seem obvious, it’s important members compare prices in this context.
- Generally, if the cost of a drug is lower than the cost share in a benefit summary, then the member will pay the lesser of the two prices (cost share in benefits summary vs. cost of the drug). For plans with deductibles:
- If a member has not met their deductible, they will pay the full cost of the drug.
- If a member has met their deductible for the plan year, they will not be charged more than the cost share in their benefit summary.
- Prescription medication costs are subject to price fluctuation just like other products and services.
- Prescriptions filled at CVS may see price changes as the company recently launched their CostVantage model which, in some cases, includes dispensing fees as part of the pharmacy’s reimbursement. (CostVantage impacts commercial members while Medicare is not impacted.
- Most Blue Shield plan designs do not require home delivery. In some cases, prescription prices through Amazon Pharmacy (the new home delivery pharmacy as of 2025) may differ from the previous home delivery pharmacy.
Not all pharmacies charge the same price to fill the same prescription. Members should compare all pricing and medication options before filling their prescriptions.
- Lower co-pays may be available at different pharmacies or through mail delivery. Members should compare prices at nearby pharmacies to find the lowest price. The "Our Pharmacy Network page" can help locate nearby pharmacy options.
- There may also be lower cost alternatives available for prescriptions such as generic or biosimilar medications.
- Blue Shield encourages the use of the member app Price Check My Rx to review medication options and guide informed decisions. Members can also learn more with this short Pharmacy Care Reimagined video.
