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Board Announces Pharmacy Benefits Plan Recommendations

On October 7, 2016 the Board announced its invitation to stakeholders to discuss plans to overhaul the way prescription medication benefits are prescribed, approved, dispensed, and paid for in New York workers’ compensation claims. The primary change will be the creation of a prescription drug formulary, which would include tiered level coverage similar to private health insurance plans, a preferred drug list, and a requirement for pre-approval of non-formulary or non-preferred medications. Additionally, the Board intends that payers will contract with Pharmacy Benefit Managers (PBMs) to administer pharmacy benefits under the new program. PBMs would be responsible for ensuring health provider compliance with established prescription guidelines, processing and paying prescription drug claims, contracting with pharmacies, and making recommendations regarding the proposed formulary. In addition, it appears that the Board intends to handle disputes over PBM prescription denials through a non-hearing based administrative process initiated by the prescribing health provider, rather than through claimants or their attorneys. Finally, the Board states the PBM should implement a Drug Utilization Review on the payer’s behalf, in part to insure compliance with the MTG’s.
According to the Board, the current system allows prescribing providers to order any medication they choose without pre-approval or prior authorization and without any process to ensure that the most effective medication is prescribed to the patient. The Board also stated that the current system, among other things, allows for price manipulation through repackaging of medications to change the average wholesale price.
The Board notes that their pharmacy benefit recommendations are part of a discussion document and invites feedback from stakeholders be submitted through its provided comment form no later than November 15, 2016.

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