THE BUFFALO NEWS
Medicaid Pharmacy Reform Greatly Needed
Dr. Andrew Symons
3/21/2023
New York is reforming its Medicaid pharmacy program to remove managed care and pharmacy benefit managers (PBMs) and directly administer these benefits for enrollees. This change cannot come soon enough.
Health insurance plans and PBMs are paid to administer the pharmacy program and patients are required to participate in one of 16 managed plans. They can only use pharmacies in the PBM network. Patients are precluded from using a pharmacy that may be in their neighborhood or close to their place of work.
When a managed care plan in Ticonderoga recently dropped one of the only two pharmacies in the area from its network, patients were unable to obtain needed medications. We must do better than having the state pay financially motivated corporations to make business decisions that disrupt and restrict patient access to needed care.
Plans have their own drug formulary. Medicaid enrollees can only use drugs on the plan formulary, which means that what may be covered for one patient may not be covered for another. The current system also imposes significant administrative burdens on prescribers to comply with the complex maze of plan requirements, protocols, processes and paperwork in order to help our patients get the drug coverage they need and deserve. Every day, physicians deal with plan and PBM denials, delays and rejections that waste their time and delay patient access to treatment.
Come April 1, News York State will launch the New York State Medicaid pharmacy program known as NYRx. It will provide one formulary covering all FDA-approved medications. NYRx has one set of rules for prescribers and will provide better access to lifesaving therapies for Medicaid patients.
The New York State Academy of Family Physicians was the first medical society in New York to advocate for a single payer system of universal health. We see the state’s decision to launch NYRx as a first and transformative step toward reform of health care in New York.
Absent enactment of single payer legislation, the academy has advocated for streamlining and standardizing health coverage to reduce administrative burdens and make health care easier to access for patients and for those who care for them. NYRx will simplify the pharmacy benefit for all with Medicaid. Patients will not be limited by pharmacy network requirements and varying plan requirements and processes. Also, removal of for-profit health plans and PBMs from this benefit will save money that can be applied to Medicaid coverage and patient services.
Health plans, PBMs and others oppose NYRx. The governor and Legislature must resist these efforts. New Yorkers with Medicaid need a simplified and standardized pharmacy benefit directly administered by New York State, as was the case a decade ago. NYRx is a model for the much broader system reforms we continue to advocate for to benefit all New Yorkers.
Dr. Andrew Symons, of Tonawanda, is president of the New York State Academy of Family Physicians.