Specialty Pharmacy Program

During negotiations for the 2007-2011 PS&T contract, PEF agreed to the implementation of an Empire Plan Specialty Pharmacy Program in order to help members and their dependents who are taking specialty medications achieve the best possible outcomes from their treatments.  By ensuring quality care, with improved clinical outcomes, the Program will also help control the rising cost of specialty medications.

Specialty medications are drugs that are used to treat complex conditions and illnesses, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis.  These drugs usually require special handling, special administration, and intensive patient monitoring.  (Medications used to treat diabetes are not considered specialty medications.)  For these reasons, not all retail pharmacies are able to dispense specialty medications.  Many drug manufacturers will only distribute these medications through designated specialty pharmacies because of the complexity of the medical conditions and the medications being used.

Whether they are administered by a health care professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service.  A list of the medications included in the Specialty Pharmacy Program is now available online at the NYS Department of Civil Service website, www.cs.state.ny.us. 

The Specialty Pharmacy Program will benefit members in a number of ways.  Members using a specialty medication will have a one-on-one relationship with a specialty-trained nurse who can help them manage their health condition, provide information about their specialty medication, and teach them how to use their specialty medication.  If the prescribing physician determines the specialty medication must be administered by a nurse, the member’s specialty-trained nurse will help him or her arrange for nursing services through the Home Care Advocacy Program.  For more detailed information on how the Program will benefit members, see the Frequently Asked Questions (FAQ).

Under the Specialty Pharmacy Program, most specialty medications will only be covered at the in-network (or highest) level of benefits when dispensed by Accredo, the Empire Plan’s Designated Specialty Pharmacy.  On or after April 1, 2010, only one fill of a prescription for a specialty medication dispensed by a pharmacy other than Accredo will be covered at the usual copayment amount.  Enrollees will have to get subsequent refills of the specialty medication from Accredo to avoid significant out-of-pocket costs. 

Refills Dispensed by Accredo

When an enrollee orders a covered specialty medication through Accredo, his or her out-of-pocket cost will be limited to the applicable mail-order copayment.  For up to a 30-day supply, the copay amount is $5 for a generic, $15 for a preferred brand name drug and $40 for a non-preferred brand name drug.  For a 31 – 90 day supply the copay amount is $5.00 for generic, $20 for preferred brand name drug, and $65 for a non-preferred brand-name drug. There are no additional costs for shipping and handling or for necessary supplies such as needles and syringes.

Refills Dispensed by a Pharmacy Other than Accredo

Enrollees will be responsible for paying the full cost of their specialty medication for refills dispensed by a pharmacy other than Accredo.  The enrollee will then have to file a claim for partial reimbursement.  An enrollee’s out-of-pocket cost will be significantly higher than the mail-order copayment amount he or she would have paid if Accredo dispensed the medication.

Enrollee Notification Letters

On 2/19/10, United Healthcare (the insurer for the Prescription Drug Program) began sending letters to those enrollees who are already using one or more specialty medications.  The letters are being sent in two phases as follows:

The letter to enrollees who currently use Accredo for their specialty medication will be mailed between 2/19/10 and 2/23/10.  Current Accredo users will not have to change pharmacies.  According to GOER, United Healthcare has identified 241 PEF-represented enrollees (employees and covered dependents) who currently use Accredo.

The letter to enrollees who currently use a pharmacy other than Accredo for their specialty medication will be mailed between 2/25/10 and 2/26/10.  The letter will notify them that Accredo will be the Empire Plan’s exclusive provider for specialty medications, and they will have to transition to Accredo to avoid significant out-of-pocket costs.  According to GOER, United Healthcare has identified 1,052 PEF-represented enrollees (employees and covered dependents) who will have to transition to Accredo.