Health plans should let customers fill specialty prescriptions at retail, N.Y. attorney general says

Eric Schneiderman sends letters to 15 health plans

NEW YORK — The state attorney general of New York is urging health insurers to let patients buy specialty drugs through retail pharmacies instead of having to use mail-order.

In a letter sent to 15 New York-based health insurance plans, Eric Schneiderman said they should adopt "specialty prescription drug fulfillment hardship exception criteria" similar to the one the office helped negotiate earlier this year with Empire BlueCross BlueShield. The letters were sent to Aetna, AXA Equitable Life Insurance Co., CDPHP, Cigna, EmblemHealth, Excellus BlueCross BlueShield, Fidelis Care New York, Healthfirst, Healthnow New York, Independent Health, MVP Health Care, Oxford Health Plans, The Guardian Life Insurance Company of America, UnitedHealth Care and WellPoint.

"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 for their local pharmacies."

Following dozens of complaints to its helpline when Empire members received notification that they would have to obtain their drugs through mail-order via Express Scripts' CuraScript specialty pharmacy starting on Jan. 1 in order to obtain coverage, the office's healthcare bureau negotiated with the insurer, leading it to allow exemptions from the mandate. Under New York state law, a commercial health plan member can obtain any covered prescription at a retail pharmacy as long as the retail pharmacy agrees by contract to accept the same reimbursement terms as the mail-order or other non-retail pharmacy.

Last week, Anthem Blue Cross settled a lawsuit filed by an advocacy group representing several specialty pharmacies and their patients in California who had sued after receiving a similar notification in mid-November.

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- 8:54 AM
mcrowe says

I am a pharmacist at Diplomat Specialty Pharmacy. Yes, there are some specialty pharmacies that provide very poor service to their patients as described in this story. And yes, I admit that I'm biased. However, there are benefits to using a specialty pharmacy that I don't believe are being considered here. The whole basis of the formation of specialty pharmacies is that the diseases specialized in are rare, the medications are extremely expensive, and most community-based pharmacists do not have enough experience in these diseases to be providing care for the patients. You cannot have every community pharmacy in the country maintaining an inventory of these medications. And, even if the community pharmacies can dispense a patient's specialty medication (many are not able to because the medication is limited distribution and not available to them), they are going to have to order it. Specialty pharmacies, when necessary, ship these medications next-day. And many specialty pharmacies provide services to patients that the community pharmacy cannot. I don't think the corner drug store pharmacy is going to collaborate with the physician to facilitate completing a prior authorization (PA), finding funding for a patient that cannot afford their medication, or file an appeal when a PA is rejected. At my specialty pharmacy we help thousands of patients get a PA for their much-needed medication and help obtain millions of dollars per MONTH so that patients can afford their medications. Again, even if a community pharmacy can dispense the medication, who is to say they have lowered the patient's out of pocket cost to something the patient can afford in the long-run. And who is to say the patient obtained all the necessary education from the pharmacy that cannot staff experts in specialty medications. Will optimal adherence be maintained? Overall, the use of the community pharmacy to provide specialty medications in order to increase access, may actually hinder patient access in the long run. There is a reason the specialty pharmacy model exists! In fact, there are many.

- 8:30 AM
jcivitel says

I agree with this comment but only in part. Yes, specialty pharmacies do perform extra care duties like obtaining PA's and educating the patients about their meds, but the fact is that only certain specialty pharmacies are currently being used by the insurance companies. As an owner of a specialty pharmacy in New York whose client base includes HIV, HCV, and Oncology patients, our specialty pharmacy does not get equal access to service these patients. You are correct to say that specialty pharmacies provide a better clinical support and service to these patients, but if a specialty pharmacy meets the criteria to do so, then they should be included in these often closed networks. By doing so, you allow more access to patients to use a "local" specialty pharmacy and not have to wait for their meds to be delivered from some out of state mail order pharmacy.

- 11:22 PM
johnspharmacy says

No sale. Specialty pharmacies did not invent helping people obtain financing or expediting PA's. Our numbers don't add up to millions per month, but we consider these practices part of routine good business. It's not about specialty vs. community pharmacies. The real distinction is good vs. poor service. (BTW...your numbers are truly impressive! If you help people obtain millions per month, and you are helping 50% of your patients, conservatively I estimate your store must do roughly $50 million per year. That's a busy store.)

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