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:
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.
Deputy for Contract Negotiation and Administration
Governor’s Office of Employee Relations
Countersigned for PEF: