Mr.
Public Employees
Federation, AFL-CIO
Dear Mr. Brynien:
This letter will confirm the
understandings reached by the parties during the negotiation of the 2007-2011
State/PEF Agreement regarding the development and implementation of an Empire
Plan Specialty Pharmacy Program.
In order to promote superior
clinical outcomes and more appropriate utilization consistent with Food and
Drug Administration (FDA) and other best practice guidelines for the use of
certain prescription drugs, the State may elect to establish an Empire Plan
Specialty Pharmacy Program. If the State
elects to do so, effective on an implementation date to be determined, the
Program will consist of a network of one or more Specialty Pharmacies.
1.
For purposes of this Program, Specialty
Drugs that will be eligible for inclusion are defined as:
“orphan drugs”;
drugs requiring
special handling, special administration and/or intensive patient
monitoring/testing;
biotech drugs
developed from human cell proteins and DNA, targeted to treat disease at the
cellular level; or,
other drugs identified by the Program as used
to treat patients with chronic or life threatening diseases.
2. Enrollees currently using, and physicians currently prescribing drugs that will be included
in the Specialty Program will be notified in writing at least 30 days in
advance of the implementation date.
3. Following
implementation, enrollees may fill one prescription for a drug included in the
Specialty Program at a Non-Specialty Network pharmacy, except for those drugs
identified as being used for short-term therapy for which a delay in starting
therapy would not affect clinical outcome.
4. Enrollees initially filling a
prescription for a Specialty Drug at a Non-Specialty Network pharmacy will be
contacted by the Program and advised that they must obtain all refills after
the allowed fill(s) through the Specialty Drug Program. Thereafter, any additional claims for the
same drug will be blocked at Non-Specialty Network pharmacies.
Beyond the initial
fill(s) described in (3) above, enrollees must contact the Specialty Referral
Line, accessible through the NYSHIP toll-free telephone line, prior to
obtaining a drug included in the Specialty Program, in order to receive the
maximum available benefit. Enrollee
calls will be transferred directly to the participating specialty pharmacy that
has agreed to provide the drug in question.
The Program
Administrator will obtain all necessary information from enrollees and
physicians in order to conduct prior authorization and enhanced case management
of the utilization of these drugs to ensure that administration will be
consistent with approved FDA indications and guidelines for administration and
nationally accepted medical protocols.
7. Once an enrollee contacts the Specialty
Referral Line, subsequent fills and refills for the same drug should be
requested directly from the Specialty Pharmacy.
8. Any
and all prescription(s), initial or refill, for
designated Specialty Drugs will be limited to a 30-day supply, unless otherwise
agreed to by the State and the Program administrator.
9. All Specialty Pharmacies that are
participating in the Specialty Drug Program will provide enrollees with
24/7/365 access to a pharmacist.
10. Drugs meeting the above definition of a
“Specialty Drug” will be excluded from coverage under the “standard” Empire
Plan Prescription Drug benefit and will be provided through the Empire Plan
Specialty Drug Program.
11. Drugs meeting the above definition of a
“Specialty Drug” that are not included in the Empire Plan Specialty Drug
benefit will continue to be covered under the “standard” Empire Plan
Prescription Drug Program.
12. Drugs included in the Specialty Drug
Program will be assigned to tiers and subject to the same copayments
as drugs covered under the “standard” Empire Plan Prescription Drug benefit.
13. Other than the accommodation described in
(3) above, drugs included in the Specialty Program that are purchased without
contacting the Specialty Referral Line will be treated as subscriber submitted
claims and will be reimbursed in the same manner as subscriber submitted claims
under the Empire Plan Prescription Drug Program: the enrollee will be
reimbursed the lesser of the pharmacy charge or the amount the Program would
have paid through the Specialty Drug Program less the appropriate copayment.
Sincerely,
John Currier
Deputy for
Contract Negotiation and Administration
Governor’s Office
of Employee Relations
Countersigned for
PEF:
President