December 30, 2020
Earlier this month the NYS Council learned that NYS residents with MMC, HARP, MLTC, CHP and Essential Health Plan insurance through Fidelis and MVP would soon have to stop using Walgreens and Duane Reade to access their medications, including medication refills, as of 1/1/2021. This health plan ‘narrowing of (pharmacy) networks’ is permitted (with prior approval) by the Office of Health Insurance Programs (OHIP) under the terms of the contract the plans currently have with the state as long as they meet network adequacy standards for pharmacy access for their insured, they seek formal approval to do so, and follow some other requirements. Apparently neither the health plans or the OHIP were obligated to communicate this change directly to the providers who work with impacted individuals or the state agencies that oversee services.
The NYS Council has been engaged on this matter with leads at the OHIP, in the Governor’s Office, and at the O agencies from the moment we learned of the situation. We have made it clear that (in our opinion) OHIP had an ethical obligation to communicate the details of these changes in a timely manner with care providers, particularly those who assist vulnerable care recipients. OHIP leaders listened and understood our concerns but also reminded us that the plans are within their rights to make these changes and can do so upon approval by OHIP given adequate notice and once the plan can show adequate (pharmacy) networks for its’ insured. Recently during a follow up meeting with OHIP leads we learned that the Office had spoken with the health plans in question, that care recipients had been told in the letter they received from the plans that they could get a 30 day supply of their medications during the month of December, and that the plans have an override process in place for those instances in which a care recipient presents at his/her Walgreens or Duane Reade pharmacy and learns that his medications are no longer available to him due to this network change. In these instances, if it isn’t offered to the care recipient automatically, the care recipient should know he/she can ask the pharmacist to call the health plan and secure an override so that medication can be provided at the time of the visit. Please make sure you this information.
In our opinion this situation is fraught with potential risk. It is impossible to overstate how important access to life saving medications including but not limited to psychotropic medications, are for the individuals we support. We are worried about the days ahead. Given the implementation date, we have pushed as hard as we can for the time being. We feel strongly that there needs to be wholesale reform of the contract between the state and the plans, and that it is not enough to rely on the health plans to voluntarily do the right thing in these instances. This is the work ahead.
Please do not hesitate to contact me if you know of a situation in which a care recipient has been denied his/her medication due to the pharmacy changes described. I will do everything in my power to help.