Fidelis, MVP and Pharmacy Changes

December 10, 2020

Last week several New York State Council members informed us that they had received a notice from Fidelis stating that, effective January 1, 2021, Walgreens and Duane Reid would no longer be part of Fidelis’ pharmacy program for HARP, Child Health Plus, Essential Plan and Medicaid Managed Care and Managed Long-term Care beneficiaries.  See link directly below for Fidelis post:

The NYS Council acted quickly to bring this to the attention of officials at the state agencies who arranged for an impromptu webinar (hosted by DOH pharmacy staff) for several association leads so we can explain to our members what is happening.  The webinar took place this morning.

Below please find our notes from the webinar:

This is about MCOs narrowing their networks and dropping certain Pharmacy Benefit Managers (PBMs) that they work with and who manage the pharmacy benefits for their HARP, Child Health Plus, Essential Plan, Managed Long-term Care, Medicaid Managed Care and other beneficiaries.
DOH rep. on the call stated that there have been many prior requests from plans to narrow their networks.  Under the terms of their contract, plans must first notify OHIP and be approved to do so.

PLEASE NOTE:  MVP is going to do the same shortly, dropping both Walgreens and Duane Reid on 1/1/2021, and these pharmacies will no longer be in MVPs network.  

All plans taking this action must give 30 day notice to beneficiaries, and beneficiaries can get a 30 day refill in advance of the change.  The Plan is required to submit info including proof that they will meet certain pharmacy access standards.  Plans must confirm through data that they have adequate pharmacy networks.  Also must share with OHIP what they are doing to ensure that members are able to access their meds after 1/1/2021.  Presumably these standards and requirements have been met by the plans making changes.

PLEASE NOTE:  On 4/1, the pharmacy benefit is coming back to Medicaid FFS for anyone receiving benefits under a Medicaid Managed Care plan.
Advocates on the call pushed hard to compel DOH leaders to reconsider the 1/1/2021 effective date for the changes mentioned above.  Apparently, according to the terms of the contract, the plan have the right to make these changes (assuming they have met network adequacy and other requirements).  It is the Office of Health Insurance Programs responsibility to ensure the plans have adequate networks.  We requested that perhaps the date for the change could be pushed back just 30 days (30 days from 1/1/2021) but it does not sound hopeful.

Please reach out to the individuals you serve each day to ensure they understand what’s happening to the best of their abilities, and share this information broadly.  We will continue to update NYS Council members regarding these very important changes.

OMH sent a notice to providers here and also shared letters that were sent to customers.