Recommendations to

Prohibit Mandatory Mail-Order Pharmacies for Medicaid Beneficiaries

A Medicaid pharmacy restrictive network program was established in the SFY2012-13 budget. Through the use of exclusive networks by Managed Care providers, often consisting of one mail-order pharmacy, Medicaid recipients are being forced to use a mail-order system for prescription drug access on drugs deemed by the New York State Department of Health as "specialty drugs."
Under the current system, the medications classified as "specialty drugs" are in most cases medications that have been dispensed to Medicaid recipients by community pharmacies for years, prior to the shift to Managed Care. It should be noted that community pharmacies continue to dispense these medications to non-Medicaid recipients.
The Supreme Court of Albany County issued an injunction on October 8, 2012 temporarily prohibiting the New York Department of Health from requiring Medicaid patients to access their medicine through a mail-order pharmacy for any of the 348 drugs on the “specialty list". The court ruled on the grounds that mail-order pharmacies might violate federal patient protections, state anti-trust laws and due process provisions in both the state and federal constitutions. Although the injunction extends through March 2013, the Managed Care plans have their own lists of "specialty drugs" and are still requiring some medications to be mail-ordered.
GMHC has received testimony from clients who have been adversely affected by this situation. Among the issues reported are missed doses of critical medication due to late or missed deliveries, and fear of a client’s HIV status exposed when a package is left in view of neighbors or coworkers through the mail-order system.

We’ve heard that patients in transitional housing situations have a particularly difficult time receiving life saving drugs on time through mail order pharmacies. And most of our clients who are in stable housing are not fortunate enough to have doormen. This leads to situations where drugs which require refrigeration are left out in the sun on summer days and expensive HIV drugs are frozen when left on a stoop in the winter.

Other clients havereceived letters from their Managed Care providers telling themthey must use a mail-order pharmacy rather than their preferred local pharmacy, despite the ruling of the court. Clients who speak English as a second language and who have relied on a local pharmacist for years because that pharmacist speaks their language are disproportionally impacted.
Consumers have the legal right to choose a local pharmacy over a Managed Care provider’s mail-order pharmacy. Local pharmacies are better suited to provide wrap-around services (e.g. counseling) than mail-order pharmacies, which often have inadequate customer service options and limited information on an individual patient’s medical history, which is necessary to monitor drug interactions between prescriptions from different providers.
To address the aforementioned issues, GMHC recommends the following:

  • Managed Care providers must comply with recently-enacted state laws governing private insurance and taxpayer-supported health plans to allow Medicaid beneficiaries to access a pharmacy of their choice.
  • Legislation permanently prohibiting Managed Care mandated mail-order pharmacies should be enacted.
  • The New York State Department of Health should enforce these laws and ensure compliance from all Managed Care providers.
  • All Mail-order pharmacies must comply with language access laws immediately.