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Schneiderman sends letters urging 15 New York health insurance plans to implement pharmacy exemption rules

by jmaloni

Press release

Mon, Jun 3rd 2013 05:25 pm

After negotiating agreement with Empire BlueCross BlueShield exempting qualifying members from specialty drug mandate, Schneiderman calls on all insurers to follow suit

Schneiderman: Those already suffering from serious illness don't deserve barriers to critical prescriptions

Attorney General Eric T. Schneiderman today sent letters to 15 New York-based health insurance plans urging them to change their policies to permit certain members to purchase specialty drug prescriptions at retail pharmacies instead of through mandatory mail-order services. The letters urge the 15 companies to adopt "Specialty Prescription Drug Fulfillment Hardship Exception Criteria" similar to one that the office of the attorney general helped negotiate earlier this year with Empire BlueCross BlueShield.

The AG's push to release health plan members from unnecessarily burdensome mail-order requirements comes as the office's health care bureau helpline has received dozens of hardship complaints relating to mail-order and non-retail pharmacies requirements from health care plan consumers.

"Every New Yorker deserves easy access to the benefits they pay for," Schneiderman said. "Those suffering from debilitating diseases like cancer, rheumatoid arthritis and HIV should not be made to suffer further hardship to get prescription drugs that are critical to their care. Exempting beneficiaries with qualifying hardships from mandatory mail-order requirements will allow plan members to continue to get the drugs they need from their local pharmacies. I commend Empire for taking this step and strongly encourage all insurance plans operating in New York to do the same."

Letters of inquiry regarding specialty pharmacy exemptions have been sent to Aetna Inc., AXA Equitable Life Insurance Company, CDPHP, CIGNA, EmblemHealth Inc., Excellus BlueCross BlueShield, Fidelis Care New York, Healthfirst, HealthNow New York Inc., Independent Health, MVP Health Care, Oxford Health Plans LLC, The Guardian Life Insurance Company of America, UnitedHealth Care, and WellPoint, Inc.

The bureau first intervened with Empire, among New York's largest health care plans, after the company notified its members that, as of Jan. 1, 2013, drugs on Empire's "Exclusive Specialty Drug List" must be purchased through its specialty mail-order pharmacy, CuraScript, and could no longer be obtained through retail pharmacies. Negotiations with Empire came as members complained that the insurance company's new mandate would pose undue hardships for them, including compromised privacy, delivery challenges and interference in physician changes in drug dosing schedules.

Empire agreed to implement procedures that will permit qualifying members to be exempted from its specialty mail-order pharmacy mandate.

New York State Law permits commercial plan members to obtain any covered prescription at a retail pharmacy rather than a mail-order or non-retail pharmacy as long as the retail pharmacy agrees by contract to accept the same reimbursement terms and conditions as the mail-order or non-retail pharmacy (such as Empire's specialty mail-order pharmacy). This law does not apply to self-funded health plans.

Drugs subject to Empire's mail-order purchase policy include prescriptions for serious and debilitating illnesses that are available from a single drug manufacturer and cost in excess of $1,200 per month. These include, among others, drugs used to treat common inflammatory conditions such as rheumatoid arthritis, psoriasis, Crohn's disease (e.g., Enbrel, Humira and Remacade); multiple sclerosis (e.g., Cepaxone, Avonex and Gilenya); cancer (e.g., Revlimid and Gleevec); Hepatitis C (e.g., Pegasis and Rebotol) and HIV (e.g., Combivir, didanosine, Retrovir and stavudine).

Empire's new hardship policy negotiated with the office of the attorney general became effective in March and the company has agreed to notify members who have filed grievances or inquiries about the new hardship exemption.

In order to fill prescriptions for drugs on Empire's Exclusive Specialty Drug List, a pharmacy must agree to maintain certain patient and clinical services. These include, for example, a 24-hour nurse or pharmacist hotline, toll-free access to patient care advocates, and disease management programs. Such requirements are not within the normal business operations of retail pharmacies.

Consumers with questions or concerns about health care matters may call the attorney general's health care bureau helpline at 1-800-428-9071.

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