BCBSNC wins State Health Plan TPA, PBM contracts

In addition to voting on preferred provider hospital systems, benefit changes, and premiums for 2027 at its Friday board meeting, the North Carolina State Health Plan Board of Trustees also awarded the Third-Party Administrator (TPA) and Pharmacy Benefit Manager (PBM) contracts to Blue Cross Blue Shield of North Carolina (BCBSNC) effective January 2028. This will bring BCBSNC back as the TPA after a three-year hiatus. CVS Caremark is the current PBM for the SHP.

“Blue Cross NC is grateful to be selected to serve the teachers, state employees, retirees, and families on the State Health Plan beginning in January 2028,” a spokesperson for BCBSNC told Carolina Journal. “As North Carolina’s only not-for-profit health insurer serving all 100 counties, we’re committed to working together with the State, hospitals, providers and members to make health care more accessible and affordable. In the months ahead, our focus is on ensuring a seamless experience for members and partnering with Plan leadership to deliver practical solutions that reduce costs and support better health outcomes.”

In April, the SHP announced that it has canceled the Request for Proposal (RFP) for Third Party Administrator (TPA) services, as none of the bids received met the RFP’s minimum requirements. The plan issued the RFP on March 20.

According to a press release, BCBSNC and Aetna were the only companies to submit bids for the TPA.

It further states that BCBSNC’s bid gives the plan the opportunity to save up to a $1 billion over the life of the contract through deeper discounts and value-based payment opportunities on top of the plan’s Preferred Provider strategy. 

Reports say the total value of the contract to the plan over three years would cost over $12 billion.

Aetna’s response

“We continue to believe Aetna is the strongest partner for the State Health Plan,” Phil Blando, a spokesman for Aetna, told Carolina Journal in an emailed statement. “Our expertise and service have helped the State Health Plan to advance its cost containment goals, successfully implement the Plan’s complex provider tiering strategy, and provide members access to high-quality care. Aetna has been a trusted partner in North Carolina for decades, and that commitment remains steadfast in continuing to support the Plan and its members through the end of the current contract, December 31, 2027. We will review this decision in the coming weeks and decide how best to move forward.” 

Multiple vendors submitted proposals across the three RFP PBM modules, including claims processing, customer service and retail network formulary strategy, utilization management and rebate administration specialty, and mail order pharmacy services, and BCBSNC was the only vendor to meet all minimum requirements established by the plan. 

The SHP awarded Aetna as the third-party administrator two years ago.

Aetna replaced Blue Cross and Blue Shield of North Carolina in January 2025 after it served as the TPA for more than 40 years.

The change occurred in 2023 under former State Treasurer Dale Folwell, who characterized the deal with Aetna as a “partnership that focuses on transparency and lower costs.”

After several appeals by BCBSNC, along with court cases, the company said in July 2024 that it would not appeal a judge’s decision upholding the shift of a State Health Plan administrator contract to Aetna. 

Blue Cross’ contract bid was $45 million lower than Aetna’s over the course of the three-year contract, according to a BCBSNC news release: “Blue Cross NC’s proposal had the lowest administrative fees and tied for first on network pricing.”

The release also touted Blue Cross as providing the broadest network of healthcare providers: “Based on a preliminary review of publicly available information, Blue Cross NC’s statewide network of total provider locations appears to be 38% larger than Aetna’s.”

“Unfortunately, Blue Cross NC was a sore loser in thinking that it was entitled to nearly a half century monopoly on the State Health Plan’s business,” Folwell added in a June 2024 press release. “They decided to try a ‘sue till you’re blue’ strategy, costing the state over $1 million in legal fees, for which taxpayers would welcome a reimbursement from Blue Cross NC. Thankfully, Judge [Melissa Owens] Lassiter saw through their legal gymnastics.”

“This administration has different priorities and would prefer a contract that is more in line with those priorities,” Loretta Boniti, director of communications and media relations for State Treasurer Brad Briner, said in an email in April. “The Plan is seeking partners who support the alignment of incentives between members, providers, and the Plan. Future partners will assist us with improving health, delivering an excellent member and provider experience, while fostering financial sustainability.” 

During the public comment period at the July 10 board meeting, a 16-year-old girl, whose family has been insured by the SHP for 20 years, told the board that Aetna has been more of an adversary than advocate in her family’s healthcare. She said she, along with her two sisters, were diagnosed with Crohn’s disease over the past few years. She said that Aetna had demanded that the girls’ medications, which had been working, be changed against their doctors’ advice and their infusion site.

After the new infusion site failed to report blood work results for her sister, creating a six-month lapse in monitoring, she had a spike in her symptoms and developed a resistance to her medication and is now looking for a new treatment protocol.

“This issue would never have happened if we were allowed to stay with her previous provider,” she told board members. “In addition, my middle sister developed a similar resistance to her medicine. Her doctor has one medicine that he feels would work well and solve her issue. We’re currently on our third denial and appeal.”

Both contract terms with BCBSNC run from Jan. 1, 2028, through Dec. 31, 2031, with two optional one-year renewal periods. 

“BCBSNC wins State Health Plan TPA, PBM contracts” was originally published on www.carolinajournal.com.