TEST

Blue Cross Blue Shield

NAVIGATOR

Blues share a name but may not share other characteristics. Sometimes
they share commonalities and work together and other times they work
completely independent of one another. This tool provides a guide to
dissecting the relationships and differences between the individual Blues
plans that can assist you to:

• Understand the role of the Blue Cross Blue Shield Association
• Detail how Blues plans work together to provide the coverage to out-of-state members
• Identify the differences among top multi-state and regional Blues plans
• Describe relationships Blues have with other third parties in the health care market

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Table of Contents Blues Affiliated PBMs

Blues Basics • Prime Therapeutics
• IngenioRx
• Blues Market
• Blue Cross Blue Shield Association Blues Network Programs

Multi-State Blues • Federal Employee Program (FEP)
• BlueCard Program
• Anthem
- AIM Health References
• Health Care Service Organization
• Cambia Health Solutions • Blues Plans Guide
• Highmark BCBS • Glossary
• References
Independent Blues

• BCBS Alabama
• BCBS Massachusetts
• BCBS Michigan
• Blue Shield of California
• Florida Blue
• Independence Health Group
• Horizon BCBS of New Jersey
• Other Independent Blues

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Blues Market

Top 5 Things to Know About Blue Cross Blue Shield Plans

1 Nearly 1 in 3 Americans are covered by a BCBS plan.1 More than 96% of hospitals
and 95% of doctors contract with BCBS companies—more than any other insurer.2

2 Medical and pharmacy management across the Blues can vary depending
on Blues’ affiliations and ownership.

3 We anticipate potential changes in PBM affiliations in the wake of mega
mergers and launch of IngenioRx.

4 Compared to their for-profit national competitors, Blues tend to be slow to
innovate or adapt to changing market conditions.

5 Blue plans are often the only carrier available in many rural areas, while urban
centers attract national plan competitors.

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Commercial Market Enrollment1

171 Million Commercial Lives | July 2018

13% 48% 14% Anthem
6%
9% 8% HCSC
1% Cambia
11% 2% Highmark
14%
23% Other Blues

Blues Plan UnitedHealth Aetna Cigna KaiserPermanente Others

Blues plans cover ~50% of all commercially insured lives in the U.S.

Across all the Blues plans, nearly all of the covered lives are in the commercial market
segment, meaning members are employer sponsored or individuals purchasing their own
private insurance. Some Blues plans have also expanded their footprint in to Medicare
and/or Medicaid.1
There are 36 Blues plans that collectively give BCBS brands a presence in all U.S. states,
the District of Columbia, and Puerto Rico.2 Each of these organizations maintain their own
decision-making processes, benefit and formulary designs, and vendor relationships.
Their decisions and product offerings are influenced by their business model and
regional characteristics.

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Blue Cross Blue Shield Association

How it Works: BCBS Association and Licenses

All Blues plan are members of the national BCBS Association3

BCBS Association licenses individual plans to use the Blue Cross and Blue Shield brand
name in specified service areas, typically a state3

Association provides services including clinical information services, group purchasing, and
patient provider service programs and designs that are optional for member plan use2

BCBS negotiates rates and benefits for federal employees2

A brief history of

Blue plans and the BCBS Association3,4

Blue Cross plans were started through a 1929 experiment in Texas to provide increased
hospital coverage to members of the community at an affordable rate.
Championed by the American Hospital Association (AHA) and its newly formed Blue Cross
Commission, the nonprofit Blue Cross plan concept flourished, creating Blue Cross plans
across other states and communities.
California Medical Association (CMA) created a nonprofit physician and medical services
plan that would be the first to take on the Blue Shield name.
The Blues organizations would continue for the next few decades providing services under
AHA standards and individual state regulations.
It was not until the 1960s that Blue Cross plans and Blue Shield plans created their own
separate associations.
The two groups merged into one in 1982, founding what is now the Blue Cross Blue
Shield Association.

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Blues plans may compete or share
state geographies

California1 Pennsylvania5,6

Anthem BC Capitol BCBS
Blue Shield of CA IBX
Highmark

The majority of Blues licenses are associated with an entire state and there is only
one Blues branded plan within a state. In a handful of states, including California,
Washington, and Idaho, there is more than one Blues plan that is allowed to serve all
counties within the state. These Blues plans compete for members directly with one
another and the other health plans of California.1
An even more unique structure is where multiple Blues plans serve specified counties
within the state and the plans do not compete against each other. Among state markets
with this structure are Missouri, New York, and Pennsylvania.5,6,7,8
Patients may not be contained to a specific licensed service area as they receive care.
It is important to understand which plan is governing coverage policies and processes
at the patient level.

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Parent PBM9 Primary Specialty
Organization1 Pharmacy9
IngenioRx
Anthem IngenioRx
14 (transitioning from
Express Scripts over (transitioning from
licensed Accredo/CVS Health
commercial states course of 2019) over course of 2019)

Blue Cross Blue Shield Association Health Care Service Prime Therapeutics AllianceRx
Corporation (HCSC) Walgreens Prime
(Ownership)
5

licensed
commercial states

Cambia Health
Solutions
4

licensed
commercial states

Highmark Express Scripts AllianceRx
Walgreens Prime
3

licensed
commercial states

Wellmark Blue CVS Health CVS Specialty
Cross Blue Shield Pharmacy
Prime Therapeutics Various
2
(9 owner/clients
licensed and 4 clients)
commercial states
Various
Independent Blues
27

licensed
commercial states

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Some Blues plans have joined forces to become multi-state entities1

Anthem (14 states) Highmark (3 states)
HCSC (5 states) Wellmark (2 states)
Cambia (4 states) Independent (27 states)

Stripes signify multiple Blues owners within state

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Multi-state Blues

Each multi-state Blues company approaches their business differently. The following
pages highlight these large organizations.

Anthem

Anthem Licensed States10,11

14 Blue States
10 Amerigroup States

Stripes represent both Blue and Amerigroup State

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Anthem Profile1

Total medical membership: 30 million
Total Rx membership: 18 million
Licensed areas: California, Colorado, Georgia, Indiana, Kentucky, Maine—Missouri counties, Nevada,
New Hampshire, New Jersey—New York counties, Ohio, Virginia (except suburban DC area), and
Wisconsin10
PBM: Express Scripts, transitioning to owned PBM, IngenioRx, in 20199

Anthem Membership Distribution

Anthem enterprise is a 19% 78%
diversified healthcare services 4%
provider, including subsidiaries12:
• AIM Specialty Health

(benefit management)
• Aspire Health

(palliative care)
• DeCare Dental
• Amerigroup

(managed Medicaid)
• HealthCore

(healthcare informatics)
• CareMore Health

(managed Medicare-Medicaid)
• HealthLink

(network rental)
• National Government

Services (Medicare
billing contractor)
• Vivity (health system)

Commercial Medicare Medicaid

Things Anthem BCBS plans are currently the only for-profit, publicly traded, licensed Blues
to Know plans.3 This adds a fiscal responsibility to their shareholders to make profits and an
additional influence on benefit design and coverage decisions.

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AIM Health Services

Anthem’s Specialty Pharmacy Medical Management
and Pathways Programs

AIM Pathway Program

CANCER CARE QUALITY PROGRAM 24 Oncology
(Brand name utilized for Anthem Pathways13
plan users)

ONCOLOGY MANAGEMENT PROGRAM ONCOLOGY SELECT 2.9M LIVES1,14 ONCOLOGY SELECT 2.4M LIVES1,15

(Alabama, North Carolina)
(Brand name utilized for external users)

• Program is voluntary and participation does not impact contracted reimbursement (ASP+%)
• Select pathways are eligible for enhanced reimbursement of $350 per month for each patient16

Specialty Pharmacy Medical Management17

While AIM may be most well known for its pathway offerings, its specialty pharmacy medical
management branch of business provides services related to specialty product coverage and
reimbursement across multiple therapeutic classes.

Specialty Pharmacy Administrative services across multiple
Medical Management therapeutic classes, including:
• Eligibility and benefits verification
• Claims submission
• Preauthorization requests

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Health Care Service Corp. (HCSC)1

HCSC Licensed States

HCSC Membership Distribution

1%
5%

94%

Commercial Medicare
Medicaid

HCSC Profile HCSC is a diversified healthcare services provider, including19:

Total medical membership: Subsidiaries: Partially owned subsidiaries:
13 million • Dearborn National • Availity (healthcare IT)
Total Rx membership: • Prime Therapeutics (PBM)
6.6 million (ancillary benefits) • TriWest Healthcare Alliance
Licensed areas: Illinois, Texas, • Dental Network of America
Oklahoma, New Mexico, • Medecision (healthcare (veteran and military health)
Montana
PBM: Prime Therapeutics9 info exchange, health
Major differentiator: Is a management platform)
mutual insurance company
owned by its policy holders.
Members have the right to
select management and share
in dividends or reductions in
premiums for excess premiums
collected.18

Things HCSC holds the largest ownership share of Prime Therapeutics.20
to Know

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Cambia Health WA
Solutions1 OR

Cambia Health Solutions
Licensed States

Cambia’s Regence Blue Cross ID Striped states include more
Blue Shield is comprised of BCBS
of Oregon, Regence Blue Shield than one BCBS licensed plan
of Washington, Regence Blue
Shield of Idaho, and Regence UT
BCBS of Utah.

Cambia Health Solutions Profile Cambia Membership Distribution

Total medical membership: 1.5 million 6%
Total Rx membership: 850,000
Licensed areas: Oregon, Washington, Idaho, Utah 94%
PBM: Prime Therapeutics9
Fully owned subsidiaries: Regence Life and
Health, Asuris Life and Health21
Major differentiator: Has chosen to stay away from
the highly profitable Medicare Advantage segment

Commercial Medicare

Things Cambia Health Solutions Blues plans operate business overlaps with that of Premera Blue Cross
to Know in Washington and BCBS of Idaho. In areas where it is not licensed to sell Blue-branded plans, its
unbranded subsidiary, Asuris Life and Health, offers a variety of insurance coverage offerings.21 The
As of July 2019 carrier has formed several narrow-network plans with major hospital systems and IDNs in order to
stay competitive in the region.22

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Highmark Blue Cross NY
Blue Shield1
Highmark Blue Cross Blue Shield
Highmark BCBS has most of its enrollment in
Licensed States Pennsylvania where it offers
plans in 65 of the state’s 67
PA DE counties (Medicaid is through
MD its Gateway Health Subsidiary).23
It has more than 500,000
WV enrollees in West Virgina and
VA more than 150,000 in Delaware.24

Striped states include more than one
BCBS licensed plan

Highmark BCBS Profile Highmark BCBS Membership Distribution

Total medical membership: 3.3 million 14%
Total Rx membership: 1.7 million 9%
Licensed areas: 65 Pennsylvania counties,
West Virginia, Delaware23 78%
PBM: Express Scripts9
Subsidiaries: United Concordia (dental insurer),
Vision-works of America (vision retailer), HM
Insurance group (stop-loss)23
Major differentiators: For its size, Highmark has
significant Medicare Advantage membership.

Commercial Medicare
Medicaid

Things Highmark is Pennsylvania’s largest carrier, and has expanded its presence with an
to Know integrated provider network.23

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Independent Blues

Independent Blues plans serve a total of 27 states. They are typically among the top
plans in their licensed market. However, market dominance and impact varies from plan
to plan. On the following pages are profiles of some of the largest independent Blues
plans that highlight what sets them apart from their peers.

Local Commercial Enrollment and Market Penetration of
Select Independent Blues25

January 2019

3.5 74%
68%

3

2.5

State commercial enrollment in millions 2 State commercial penetration

1.5 39% 36%

32%
1

0.5 3.5 15% 15% 1.4
BCBS 1.9 2.9 1 1.9
3.4 Michigan
0 Horizon Blue Independence BCBS BCBS
BCBS (NJ) Shield (CA) Health (PA) Alabama Massachussetts
Florida Blue

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Blue Cross Blue Shield of Alabama1 BCBS Alabama
Membership Distribution
Total medical membership: 2.9 million
Total Rx membership: 1.5 million 3%
PBM: Prime Therapeutics9
Major differentiators: Alabama Blue is one of the 97%
nation’s most dominant state-based plans, with more 75%
commercial market share, giving it outsized clout
in negotiation with providers and vendors26

Commercial Medicare

Things The Alabama Blues plan serves nearly one million people that reside outside of its
to Know Alabama service area.26

Blue Cross Blue Shield of Massachusetts1 BCBS Massachusetts
Membership Distribution
Total medical membership: 2.2 million
Total Rx membership: 1.6 million 3%
PBM: Express Scripts9
Major differentiators: BCBS Massachusetts is 97%
implementing a plan to base all provider payments
on quality, outcomes, safety, and efficiency. These
Alternative Quality Contracts combine global payments
per patient and performance incentives tied to quality
and efficiency measures.27

Commercial Medicare

Things BCBS Massachusetts uses its subsidiary, Blue Benefit Administrators, to offer Blues
to Know branded offerings to large self-insured employers.28

As of July 2019 16

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Blue Cross Blue Shield of Michigan1 BCBS Michigan
Membership Distribution
Total medical membership: 4.2 million
Total Rx membership: 2.6 million 5%
PBM: Express Scripts9 12%
Fully owned subsidiaries: Blue Care Network of Michigan,
AF Group, LifeSecure Insurance Company, Advantasure, Blue 83%
Cross and Blue Shield of Michigan Foundation29
Major differentiators: Michigan Blue subsidiary Blue Care
Network is the state’s largest HMO and the only HMO available
in Michigan’s Upper Peninsula. It is a key piece in the insurer’s
market strength.30

Commercial Medicare
Medicaid

Things The Michigan Blue plan operates Collaborative Quality Initiatives in 17 areas of care. Its
to Know medical home Value Partnership Program extends to approximately 90 hospitals, over 40
physician groups, and 19,000 physicians.31

Blue Shield of California1 BlueShield CA
Membership Distribution
Total medical membership: 3.4 million
Total Rx membership: 2.6 million 2%
PBM: CVS/Caremark9 4%
Major differentiators: In one of the few states where Blue
Cross and Blue Shield licenses are not consolidated, Blue Shield 93%
of California competes directly with for-profit Anthem Blue
Cross of California.32

Commercial Medicare
Medicaid

Things Blue Shield is heavily involved with CalPERS, which covers California state employees and 17
to Know retirees. Blue Shield is an accountable care pioneer, forming an ACO with Dignity Health
and Hill Physicians Medical Group for CalPERS members.33
As of July 2019
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Florida Blue1 Florida Blue
Membership Distribution
Total medical membership: 4.1 million
Total Rx membership: 2.8 million 2%
PBM: Prime Therapeutics9
Ownership: Florida Blue is owned by holding company 4%
GuideWell, which also counts Capital Health Plan, Florida
Healthcare Plans, and Florida True Health among its 94%
subsidiaries.34
Major differentiators: Florida Blue is one of the nation’s
largest health exchange carriers, with more than 1 million
individual members. It has a stronger Medicare Advantage
presence than most independent Blue plans.

Commercial Medicare
Medicaid

Things Florida Blue is involved in 20 ACOs throughout Florida. Two of the ACOs are oncology
to Know focused: one in south Florida with Baptist Health South Florida and the other in Tampa
with Moffitt Cancer Center.35

Independence Health Group1 Independence Health (IBX)
Membership Distribution
Total medical membership: 2.7 million
Total Rx membership: 2.4 million 4%
Licensed areas: Five counties in eastern Pennsylvania6
PBM: Future Scripts9 43%
Fully owned subsidiaries: AmeriHealth, AmeriHealth 54%
Administrators (TPA), AmeriHealth Caritas (Medicaid MCO
owned in partnership with BCBS of Michigan), NaviNet, Inc.
(payer-provider administration), Tandigm Health (population
Health, value-based network)36
Major differentiators: Rare among the Blue plans, it has more
Medicaid membership than it does commercial membership

Commercial Medicare
Medicaid

Things IBX Blues-branded offerings in the self-insured market cater to small businesses, 18
to Know but it also targets large, multi-state employers with non-Blues offerings through
its TPA subsidiaries.37
As of July 2019
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Horizon Blue Cross Blue Shield of New Jersey1

Total medical membership: 3.5 million Horizon BCBS
Total Rx membership: 1.7 million Membership Distribution
Affiliates territories: New Jersey
24%
PBM: Prime Therapeutics9 76%
Subsidiaries: Horizon BCBS NJ
Dental, Horizon Casualty Service, 1%
Horizon NJ Health38

Major differentiators: Horizon has
a large block of Medicaid business,
which grew substantially due to New
Jersey’s Medicaid expansion.

Commercial Medicare Medicaid

Things Horizon has a high volume of out-of-state memberships due to sharing borders with the massive
to Know New York City and Philadelphia markets. Nearly 80% of Horizon BCBS of New Jersey enrollment
is in its home state of New Jersey, but it also has a large number of enrollees in Pennsylvania and
significant enrollment in the Midwest and along the eastern seaboard into Florida, as well as
Texas and California.39

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Other Independent Blues Plans1 (as of January 2019)

Independent Blue Primary Total medical Commercial Total Rx Home state Primary PBM9 Primary
State membership membership membership commercial specialty
Arkansas BCBS as percent market pharmacy9
BCBS Arizona AR 630,000 of total penetration25 AllianceRx
AZ 575,000 Walgreens Prime
73% 460,000 34% CVS Health BriovaRx

91% 415,000 13% OptumRx

BCBS Hawaii HI 805,000 76% 730,000 79% CVS Health CVS Health

BlueCross Idaho ID 335,000 91% 250,000 32% CVS Health CVS Health
Wellmark BCBS IA 570,000 100% 580,000 26%
(IA, SD) KS 585,000 100% 475,000 34% CVS Health CVS Health
BCBS Kansas LA 1 million 99% 635,000 53%
Prime (Owner) AllianceRx
BCBS Louisiana Walgreens Prime

Express Scripts Accredo

CareFirst (DC, MD, VA) MD 2.4 million 100% 1.1 million 45% CVS Health CVS Health
2.4 million 80% 1.4 million 59%
BCBS Minnesota MN 480,000 100% Prime (Owner) AllianceRx
615,000 98% Prime Walgreens Prime
BCBS Mississippi MS 565,000 100% 225,000 35% AllianceRx
BCBS Kansas City MO 1.5 million 74% Walgreens Prime
BCBS Nebraska NE
Excellus BCBS (NY) NY 450,000 11% Express Scripts Accredo

380,000 33% Prime (Owner) AllianceRx
Walgreens Prime

1.1 million 13% Express Scripts Accredo

HealthNow New York NY 400,000 76% 370,000 4% Express Scripts Accredo
BCBS North Carolina NC 2.4 million 97%
165,000 99% 1.5 million 36% Prime (Owner) AllianceRx
470,000 90% Prime (Owner) Walgreens Prime
BCBS North Dakota ND 215,000 76% 155,000 33% CVS Health AllianceRx
1.2 million 91% Prime (Owner) Walgreens Prime
Capital BlueCross (PA) PA 340,000 6% AllianceRx
Walgreens Prime
BCBS Rhode Island RI 200,000 31% AllianceRx
BCBS South Carolina SC 880,000 45% Walgreens Prime

CVS Health CVS Health

BCBS Tennessee TN 2.5 million 65% 1 million 35% Express Scripts Accredo

BCBS Vermont VT 170,000 100% 100,000 52% Express Scripts Accredo
Premera Blue Cross
(AK, WA) WA 1.1 million 95% 975,000 16% Express Scripts Accredo
BCBS Wyoming
Triple-S Management WY 75,000 100% 55,000 22% Prime (Owner) AllianceRx
(PR) Walgreens Prime

As of July 2019 PR 855,000 51% 760,000 43% Abarca Health Abarca Health

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Blues Affiliated PBMs

Blue Cross Blue Shield plans and their PBM affiliations9

Most BCBS Association plans handle pharmacy benefit design and formulary management in-house,
but rely on PBMs for claims adjudication, and pharmacy network in addition to other services.

Click on each marker for more data.

PBM Affiliations Express Scripts Stripe (PBM varies by Blues within state)
Future Scripts
Anthem (Express/IngenioRx) Optum

Prime Therapeutics

CVS/Caremark

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Prime Therapeutics

Blues-owned PBM9,40

Many of the Blues plans that utilize Prime also have an ownership stake

Prime Blues

Owners and Clients
Only Clients
Medicare Part D Client
Specialty Pharmacy
Only Client
Stripes signify only one of
the state’s Blues plans is a
Prime Owner

Blue-owned (HCSC is the largest owner) Prime Therapeutics provides services to 22
Blues plans and directly to some employers. While some Blues have an ownership
stake in the PBM, others utilize the company for specific services.20

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Prime Therapeutics

Serves multiple Blues plans9,20,41

Prime’s connection with Blue plans means it can integrate pharmacy and medical
claims to drive clinical coordination for its clients and improve outcomes for its
members. It has a strategic partnership with Walgreens that includes a jointly
owned specialty pharmacy and mail services company, Alliance Rx.

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IngenioRx

Anthem’s New PBM

Anthem launching IngenioRx in 2019

Expected to be fully operational during 201942

• Anthem will fully transition all pharmacy covered lives from Express Scripts
throughout 2019

Hybrid model between Anthem and CVS Health42

• Anthem will manage formulary and benefit design, prior authorization, clinical strategy,
medication therapy management, and network management

• CVS Health will provide claims processing and fulfillment

Ability to integrate pharmacy and medical benefit data43

• Anthem executives see potential clinical and cost-saving advantages in IngenioRx’s
ability to integrate pharmacy and medical benefit data and work with pharmacists to
address gaps in care and medication adherence issues

Anthem is planning to sell PBM services beyond the Anthem footprint42

• Anthem is counting on IngenioRx to provide an estimated $4 billion in annual cost-savings,
enhanced data integration, and a new profit center

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Blues Network Programs

Federal Employee Program (FEP)44

Coverage Policies Blues FEP plan has its own medical policies
and coverage criteria (prior authorization and
other restrictions)

Role of Blues Plans FEP members are served through any
Blues plan. On behalf of FEP members,
local Blues plans:

• Process claims
• Provide network and customer service

FEP Covers Offered to full-time government employees
and qualified retirees throughout the US
5.3 million members

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Blue Card Program

Although individual Blue plans operate independently, they do share a
common thread of cooperation that differentiates them from other health plans:
the BlueCard network.

BlueCard gives local Blue plans a national—
and sometimes international—reach45

• All Blues plans participate in the BlueCard program
• BlueCard allows out-of-area BCBS members access to the provider network of the local

Blue plan
• Members have a Home Blue plan and a Host Blue plan: Home Blue is the insurer and Host

Blue provides the local network46
• Local Blue plans can tout a national provider network and compete with national for-profits

like Aetna, UnitedHealth, and Cigna (the same is true of Anthem, which has 14 Blue licenses
but the same national network)

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Member IDs show suitcase for BlueCard
coverage, empty suitcase for non-PPO coverage46

Suitcase logo with PPO gives This member has out-of-area coverage,
members access to the Host Blue but not PPO coverage, so will likely
have more limited provider options
plans entire PPO network

Real World Example: The Patient Journey46 Click on each circle for more information

Patient leaves Michigan and is in Florida receiving treatment

Step 1 Step 3

FL

MI

Step 4

Step 2

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Blues Plans Guide1

Blues Plan Primary Total medical Commercial Total Rx Primary state Primary
Service membership membership membership commercial Primary PBM9 specialty
State (when as percent market
of total penetration25 pharmacy9
applicable)

Anthem 14 states 30 million 78% 18 million N/A IngenioRx IngeioRx
Health Care 5 states 13 million 94% 6.6 million N/A
Service Corp. 4.1 million 94% Prime (Owner) AllianceRx
4.2 million 84% Prime (Owner) Walgreens Prime
Florida Blue FL 3.5 million 70% 2.8 million 32% AllianceRx
3.4 million 93% Walgreens Prime
3.3 million 78%
BCBS of MI 2.7 million 57% 2.6 million 68% Express Scripts Accredo
Michigan NJ 2.9 million 95%
Horizon BCBS CA 2.4 million 80% 1.7 million 39% Prime (Owner) AllianceRx
of New Jersey 2.5 million 65% Walgreens Prime
BlueShield of 2.4 million 100%
California 2.4 million 97% 2.6 million 15% CVS Health CVS Health
2.2 million 96%
Highmark BCBS 3 states 1.5 million 94% 1.7 million N/A Express Scripts AllianceRx
1.5 million 74% Walgreens Prime
1.1 million 95%
Independence PA 1.2 million 91% 2 million 15% Future Scripts BiovaRx
Health Group AL 1 million 99%
BCBS of 805,000 76% 1.6 million 74% Prime (Owner) AllianceRx
Alabama 615,000 98% Prime (Owner) Walgreens Prime
AllianceRx
BCBS Minnesota MN 1.4 million 59% Walgreens Prime
1 million 35%
BCBS Tennessee TN 1.1 million 45% Express Scripts Accredo

CareFirst MD CVS Health CVS Health
(DC, MD, VA) NC
BCBS North MA 1.5 million 36% Prime (Owner) AllianceRx
Carolina 4 states Walgreens Prime
BCBS of NY
Massachusetts WA 1.6 million 36% Express Scripts Accredo
Cambia Health SC
Solutions 850,000 N/A Prime (Owner) AllianceRx
Excellus Walgreens Prime
BCBS (NY)
Premera Blue 1.1 million 13% Express Scripts Accredo
Cross (AK, WA)
BCBS South 975,000 16% Express Scripts Accredo
Carolina
880,000 45% CVS Health CVS Health
635,000 53%
BCBS Louisiana LA 730,000 79% Express Scripts Accredo
450,000 11%
BCBS Hawaii HI CVS Health CVS Health
BCBS MO
Kansas City Express Scripts Accredo

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Blues Plans Guide (cont.)

Blues Plan Primary Total medical Commercial Home state Primary
Service membership membership Total Rx commercial Primary PBM specialty
Wellmark BCBS State (when as percent membership market
(IA, SD) of total penetration pharmacy
BCBS Arizona applicable)

IA 570,000 100% 580,000 26% CVS Health CVS Health

AZ 575,000 91% 415,000 13% OptumRx BriovaRx

BCBS Nebraska NE 565,000 100% 380,000 33% Prime (Owner) AllianceRx
Prime (Owner) Walgreens Prime
BCBS Kansas KS 585,000 100% 475,000 34% AllianceRx
400,000 76% 370,000 4% Walgreens Prime
470,000 90% 340,000 6%
HealthNow NY 630,000 73% 460,000 34% Express Scripts Accredo
New York 480,000 100% 225,000 35%
Capital PA 335,000 91% 250,000 32% CVS Health AllianceRx
BlueCross (PA) AR 215,000 76% 200,000 31% Walgreens Prime
Arkansas BCBS MS 170,000 100% 100,000 52%
BCBS ID 165,000 99% 155,000 33% CVS Health Prime
Mississippi RI 75,000 100% 55,000 22%
BlueCross Idaho VT 855,000 51% 760,000 43% Prime (Owner) AllianceRx
BCBS ND Walgreens Prime
Rhode Island
BCBS Vermont CVS Health CVS Health
BCBS
North Dakota Prime (Owner) AllianceRx
Walgreens Prime

Express Scripts Accredo

BCBS Wyoming WY Prime (Owner) AllianceRx
Prime (Owner) Walgreens Prime
AllianceRx
Walgreens Prime

Triple-S PR Abarca Health Abarca Health
Management (PR)

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.

Glossary

Blue Cross Blue Shield Association2,3

BCBS plans’ national association. While the association holds no ownership in individual Blues plans,
it is responsible for licensing the Blue Cross and Blue Shield brands to health insurers and controlling
licensed service areas for those plans. The association also provides multiple programs and services
to Blues plan members.

BlueCard Program45

A national BCBS Association program that enables members of any BCBS plan to obtain healthcare
services while traveling or living in another BCBS plan service area. All Blues plans participate, but
not all employers purchase the offering.
• Home Blue/Plan46: The BCBS plan that the members obtained health insurance coverage

through. Home Blue governs coverage decisions for patient.
• Host Blue/Plan46: The BCBS plan serving the area where a BCBS member obtains care while

living or traveling outside of their home state service area. The Host Blue administers the care
and processes claims.

Commercial Enrollment/Lives47

Health insurance coverage sponsored by employer or other private group, or purchased directly by
an individual from a private insurer.

Federal Employee Program (FEP)44

Also known as the Federal Employee Health Benefit Program, it is the system through which civilian
federal employees obtain employer health insurance. The BCBS Association negotiates with the
Office of Personnel Management for the benefits that all Blues plans will provide to Blues enrolled
FEP members throughout the country.

Licensed Area3

Geographic area in which a Blues plan is permitted by the BCBS Association to market and sell its
Blues-branded products and services.

Medical Enrollment

Lives covered by an health insurer for hospital and medical services and products.

Mutual Insurance Company18

A mutual insurance company is owned by policy holders and its members are given the right
to select management. Members of a mutual insurance company have the right to excess
premiums, meaning that if losses and expenses are less than the amount of premiums paid
into the company, the members would receive either a dividend payment or a reduction in
premiums (for example, HCSC).

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.

Pathway Program48

Standardized care and treatment map for a specific diagnosis. Pathways guide a patient’s plan
of care through attainment of specific clinical outcomes by the patient from regimen initiation to
completion of treatment.

Pharmacy/Rx Enrollment

Lives covered by an health insurer for prescription drug products.

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.

References

1. Decision Resources Group. Managed Market Surveyor Suite January 2019 – National Enrollment.
https://mms.decisionresourcesgroup.com/file-downloads. Accessed July 5, 2019.

2. Blue Cross Blue Shield Association. Blue Facts. https://www.bcbs.com/sites/default/files/file-attachments/
page/BCBS.Facts__0.pdf. Accessed July 5, 2019.

3. Becker’s Hospital Review. 25 Things to Know about Blue Cross Blue Shield. https://www.beckershospitalre-
view.com/payer-issues/25-things-to-know-about-blue-cross-blue-shield.html. Accessed July 5, 2019.

4. Consumer Reports. Blue Cross and Blue Shield: A Historical Compilation. https://advocacy.consumerre-
ports.org/wp-content/uploads/2013/03/yourhealthdollar.org_blue-cross-history-compilation.pdf.
Accessed July 5, 2019.

5. Capital Blue Cross. FAQ. https://www.capbluecross.com/wps/portal/cap/home/explore/resource/mem-
ber-faq. Accessed July 5, 2019.

6. Independence Blue Cross. Our Company. https://www.ibx.com/company_info/our_company/bcbs.html.
Accessed July 5, 2019.

7. Anthem. About Anthem. https://www.anthem.com/about/. Accessed July 5, 2019.

8. Lifetime Healthcare Companies. Excellus BlueCross BlueShield Service Area. https://www.excellusbcbs.
com/webcontent/docs/map.html. Accessed July 5, 2019.

9. Decision Resources Group. Managed Market Surveyor Suite January 2019 – Formulary Management.
https://mms.decisionresourcesgroup.com/geography?coverage_view=pbm&date=2019-01-01&state=na-
tionalinc. Accessed July 5, 2019.

10. Anthem. Company History. https://www.antheminc.com/AboutAnthemInc/CompanyHistory/index.htm.
Accessed July 5, 2019.

11. Amerigroup. The States We Serve. https://www.amerigroup.com/the-states-we-serve.html. Accessed
July 5, 2019.

12. Anthem. Affiliated/Specialty Companies. https://www.antheminc.com/Companies/AffiliatedSpecialtyCom-
panies/index.htm. July 5, 2019.

13. Anthem. Cancer Care Quality Program Treatment Pathways. https://cancercarequalityprogram.com/
pdf/2019/May13/Anthem_Workbook.pdf. July 5, 2019.

14. BlueCross BlueShield of Alabama. Oncology Select. https://providers.bcbsal.org/portal/resources/-/re-
sources/category/318524. Accessed July 5, 2019.

15. BlueCross BlueShield of North Carolina. Medical Oncology Program and Cancer Treatment Pathways.
https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/news-and-in-
formation/news/Cancer%20Treatment%20Pathways%20FAQs.pdf. Accessed July 5, 2019.

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.

16. Anthem Cancer Care Quality Program. Reimbursement FAQs. https://cancercarequalityprogram.com/pdf/
EnhancedReimbursementFAQ.pdf. Accessed July 5, 2019.

17. AIM. Specialty Health Solution. https://www.aimspecialtyhealth.com/Solution-AIMInform.html. Accessed
July 5, 2019.

18. Investopedia. Mutual vs. Stock Insurance Companies. https://www.investopedia.com/articles/personal-fi-
nance/011916/mutual-vs-publically-traded-insurance-companies.asp. Accessed July 6, 2019.

19. Health Care Service Corporation. Affiliates and Subsidiaries. https://www.hcsc.com/who-we-are/affili-
ates-subsidiaries. July 6, 2019.

20. Decision Resources Group. PBM Profile Prime Therapeutics. 2019. https://mms.decisionresourcesgroup.
com/file-downloads. Accessed July 6, 2019.

21. Cambia Health Solutions. Health Insurance Services. https://www.cambiahealth.com/companies/health-in-
surance. Accessed July 6, 2019.

22. Decision Resources Group. Health Plan Profile Cambia Health Solutions 2019. http://www.hl-isygateway.
com/reportaction/HPPPOR1220/Toc. Accessed July 6, 2019.

23. Decision Resources Group. Health Plan Profile Highmark 2019. http://www.hl-isygateway.com/reportac-
tion/HPPPPA1095/Toc. Accessed July 6, 2019.

24. Decision Resources Group. Managed Market Surveyor Suite January 2019 – Highmark Profile. https://
mms.decisionresourcesgroup.com/health-plan?benefit_type=Medical&date=2019-01-01&paren-
tid=1095&payerid=&sort_key=overall&state=nationalinc. Accessed July 6, 2019.

25. Decision Resources Group. Managed Market Surveyor Suite January 2019 – State Enrollment. https://
mms.decisionresourcesgroup.com/file-downloads. Accessed July 5, 2019.

26. Decision Resources Group. Managed Market Surveyor Suite January 2019 – Blue Cross and Blue Shield
of Alabama Profile. https://mms.decisionresourcesgroup.com/health-plan?benefit_type=Medical&-
date=2019-01-01&parentid=975&payerid=&sort_key=overall&state=nationalinc. Accessed July 6, 2019.

27. Decision Resources Group. Health Plan Profile Blue Cross and Blue Shield of Alabama 2019. http://www.
hl-isygateway.com/reportaction/HPPPPA1095/Toc. Accessed July 6, 2019.

28. Blue Benefit Administrators of Massachusetts. Why BBA. https://www.bluebenefitma.com/why-bba.
Accessed July 6, 2019.

29. Blue Cross Blue Shield Blue of Michigan. Fast Facts. https://www.bcbsm.com/index/about-us/our-compa-
ny/fast-facts.html. Accessed July 6, 2019.

30. Blue Cross Blue Shield Blue Care Network. Fast Facts. https://www.bcbsm.com/index/about-us/our-com-
pany/about-bcn/fast-facts.html. Accessed July 6, 2019.

31. Blue Cross Blue Shield Blue Care Network. Value Partnerships Overview. https://www.bcbsm.com/provid-
ers/value-partnerships/value-partnerships-overview.html. Accessed July 6, 2019.

32. Health for California. Blue Cross vs. Blue Shield in California: Provider Network is the Key Difference.
https://www.healthforcalifornia.com/blue-cross-vs-blue-shield-in-california-provider-network-is-the-key-dif-
ference. Accessed July 7, 2019.

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.

33. Decision Resources Group. Health Plan Profile Blue Shield of California 2019. http://www.hl-isygateway.
com/reportaction/HPPPCA979/Toc. Accessed July 7, 2019.

34. GuideWell. Insurance. http://www.guidewell.com/our-companies/insurance/. Accessed Jul7 7, 2019.
35. Decision Resources Group. Health Plan Profile Florida Blue 2019. http://www.hl-isygateway.com/reportac-

tion/HPPPFL982/Toc. Accessed July 7, 2019.
36. Independence Blue Cross. Affiliates. https://www.ibx.com/company_info/our_company/affiliates.html.

Accessed July 7, 2019.
37. Decision Resources Group. Health Plan Profile Independence Health Group 2019. http://www.hl-isygate-

way.com/reportaction/HPPPFL982/Toc. Accessed July 7, 2019.
38. Horizon Blue Cross Blue Shield of New Jersey. Family of Companies. https://www.horizonblue.com/about-

us/our-company/family-of-companies. Accessed July 7, 2019.
39. Decision Resources Group. Managed Market Surveyor Suite January 2019 – Horizon Blue Cross Blue

Shield of New Jersey Profile. https://mms.decisionresourcesgroup.com/health-plan?benefit_type=Medi-
cal&date=2019-01-01&parentid=1099&payerid=&sort_key=overall&state=nationalinc. Accessed
July 6, 2019.
40. Prime Therapeutics. Owner Clients. https://www.primetherapeutics.com/en/news/Resources/clients.html.
Accessed July 7, 2019.
41. Prime Therapeutics. Who is Prime Therapeutics. https://www.primetherapeutics.com/en/news/Resources/
companyinfo.html. Accessed July 7, 2019.
42. Truveris. Anthem to Transition Members to IngenioRx PBM 10 Months Sooner Than Expected. https://
www.truveris.com/resources/anthem-to-transition-members-to-ingeniorx-pbm-10-months-sooner-than-ex-
pected. Accessed July 7, 2019.
43. Anthem. https://www.crnstone.com/wp-content/uploads/2019/03/IngenioRx-Transition-ABCBS-Cli-
ent-Guide-022019vF-1.pdf. Accessed July 7, 2019.
44. Blue Cross Blue Shield Association. About the Federal Employee Program (FEP). https://www.fepblue.org/
about-fep. Accessed July 7, 2019.
45. Blue Cross Blue Shield Association. Nationwide Access and Local Support: What It Means for Blue
Members. https://www.bcbs.com/articles/nationwide-access-and-local-support-what-it-means-blue-mem-
bers. Accessed July 7, 2019.
46. Blue Cross California Medicare Rx. How Does the Blue Card Program Work? https://bluecrosscamedi-
carerx.com/wps/portal/ahpprovider?content_path=provider/ct/f5/s2/t0/pw_036847.htm&state=ct&root-
Level=4&label=How%20Does%20the%20BlueCard%20Program%20Work?. Accessed July 7, 2019.
47. Investopedia. Commercial Health Insurance. https://www.investopedia.com/terms/c/commercial-health-in-
surance.asp. July 7, 2019.
48. Open Clinical. Clinical Pathways. http://www.openclinical.org/clinicalpathways.html. July 7, 2019.

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As of July 2019 FOR INTERNAL USE ONLY. DO NOT DUPLICATE, DISTRIBUTE, OR USE IN PROMOTION.