Historic Progress Made in Reforming Medicaid in New York State-Patient Centered Medical Home

New York spends more on Medicaid per capita than any other state in the nation, but we rank only 21st in program quality for patients. In most counties, Medicaid costs alone account for more than half of the entire county tax levy.

To reform the system, Governor Cuomo created a Medicaid Redesign Team. The Team — comprised of health care professionals, stakeholders, and legislators — was charged with reducing costs and improving patient care. The Team held open meetings throughout the state and reviewed more than 4,000 ideas from team members, outside health care professionals, and citizens.

Last week, the Team accomplished their goal, submitting an unprecedented consensus plan that meets the Governor’s budget target and saves over $2.3 billion. What’s more, under the plan, one million New Yorkers will now have access to an innovative “patient-centered” medical program, making New York the national leader in providing this type of personal care. Today, the legislation to enact the plan was submitted to the Legislature to be included as part of the Executive Budget.

If you would like more information on this historic plan, click here to read about the Medicaid report.

Oxford Changes Tier 3 Prescription Drug Rules for NY Small Groups

As drug costs continue to rise, carriers are creating innovative ways for members to maintain affordable access to a variety of medications. Oxfords Select Designated Pharmacy Program, for example, focuses on providing members with access to lower cost alternatives to a select number of Tier 3 (high-cost) medications. This program will be implemented for Oxford fully insured New York small groups (2-50 lives) on January 1, 2011. The program does not apply to Healthy NY plans, and is optional for self-funded groups. 

About the program  Members of the program are required to choose one of three cost-saving options to continue to receive medications at the in-network benefit level:              

  • Option 1: Switch to a lower-cost medication and save
  • Option 2: Fill the prescription through the Mail-Order Pharmacy and save
  • Option 3: Do both to save 

Members are allowed two “grace” fills of their current medication at the retail pharmacy before they must select a new option. If a member chooses to continue filling a Tier 3 medication at the local retail pharmacy after the second grace fill, the member will pay the full cost of the medication, as benefits are not payable under the plan.

 Medications included in the program The targeted medications and products listed below, all in Tier 3, represent 2% of all retail prescriptions. The majority of these have multiple, lower-cost alternatives.

Medications

Lyrica, Symbicort, Avodart, Uroxatral, Lexapro, Atacand, Atacand HCT, Avapro, Avalide, Asacol, Asacol HD, Axert, Frova, Maxalt, Maxalt MLT, Zomig, Zomig ZMT, Toviaz and Detrol.

All employers will receive a letter from Oxford about the Select Designated Pharmacy Program as well as all members that are currently taking these medications. Members will also receive an outgoing call from Oxford, and point -of-sale messaging at the retail pharamacy to help them understand their options for savings.

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