Monthly Archives: June 2018

EMBLEM Health expands NY NJ CT Network

EmblemHealth’s Tristate Network for Small Groups: Available to Quote Now
EmblemHealth has expanded our Prime network for small groups (1-100 employees) to include both the QualCare network in New Jersey and ConnectiCare’s network in Connecticut. The expanded Prime network will be effective for these groups July 1, 2018.

Empire Blue Cross terminates South Nassau Community Hospital

From Empire Blue Cross: “We are actively negotiating a renewal deal but we have reached a point where we are proceeding with the activities to terminate our contract effective 5/1/18.  The 60 day cooling off period ends 7/1/18 , on 5/15/18 notification letters were mailed to our members. As always we are continuing our dialogue with the facility in the hopes of reaching a mutually acceptable agreement.”

Therefore as of 7/1, at the end of the cooling off period, if no deal has been reached, South Nassau will be out of the network.

 

Blue States fight Association Health Plans

At least two states (Massachusetts and New York) are threatening to sue the Trump administration over this new rule…. In several states, group health insurance laws will need to be revised to permit individuals and small groups to participate in AHPs if they are not otherwise members of pre-existing tax-qualified bona fide associations…. Many states do not permit the inclusion of sole proprietors and individuals in group insurance arrangements.

This may shape up as a battle between Federal and State rights, Liberals and Conservatives.  In any event, no state to our knowledge has yet to approve any association health plans.

 

From Crains:  “The state Department of Financial Services said Tuesday that the Trump administration’s final rule expanding the role of association health plans won’t preempt its authority to regulate health insurance. ”  DFS Superintendent Maria Vullo said in a statement. “As always, DFS will enforce New York law and regulation to ensure consumers continue to enjoy the state’s robust health care consumer protections.” State officials and insurance experts have expressed concern that the expansion of association health plans will attract healthier customers seeking cheaper, less comprehensive coverage. That would leave behind a sicker pool of people seeking coverage in the state’s small-business and individual markets, which would lead to insurers’ raising prices for all customers.

NY State fights back on $272,000 Orkambi Drug Cost

From MSN Money:  Click here

 

A wave of breakthrough drugs is transforming the medical world, offering hope for people with deadly diseases despite their dizzying price tags.

But what if it turns out that some of these expensive new drugs don’t work that well?

That’s the quandary over Orkambi, a drug that was approved in 2015 for cystic fibrosis and was only the second ever to address the underlying cause of the genetic disease. Orkambi, which is sold by Vertex Pharmaceuticals, costs $272,000 a year, but has been shown to only modestly help patients.

Now, in a case that is being closely watched around the country, New York state health officials have said Orkambi is not worth its price, and are demanding that Vertex give a steeper discount to the state’s Medicaid program. The case is the first test of a new law aimed at reining in skyrocketing drug costs in New York’s Medicaid program.

Blue Cross Blue Shield SC Formulary Changes

Exclusions for many certain high-cost brand drugs that are no more effective than medications already available are among the latest updates to BlueCross BlueShield of South Carolina’s drug formulary, with most of the changes taking effect July 1, 2018.

We work with an independent panel of BlueCross network physicians and pharmacists, the Pharmacy and Therapeutics Committee, to develop and maintain our drug lists and policies. Clinical decisions are based on drugs’ efficacy, safety and value, with the goal of providing the greatest clinical effectiveness for the lowest cost.

The particular brand-name drugs affected by this update are usually launched a couple of years after a new brand-name drug is introduced. “Structurally, they are very similar to drugs already on the market,” said Joshua Arrington, who is pharmacy sales director for BlueCross as well as a licensed pharmacist.

The newer versions aim to capture their own share of the market as manufacturers promote them as providing additional value. But because they are so similar to the original drugs, they offer no clinical benefit to patients — and after initial discounts wear off, they don’t offer additional cost savings, either.

The new Update Bulletin from our Pharmacy Management department includes an A-to-Z (Aczone to Zofran) list of drugs that will be excluded as of July 1, as well as alternative medications that are covered. Arrington mentioned some examples of the savings involved:

  • Doryx averages $1,000 per prescription. Its generic alternative doxycycline is $18.
  • Amrix averages $1,000 per prescription. Its generic alternative cyclobenzaprine is $10.
  • Gralise averages $660 per prescription. Its generic alternative gabapentin is $15.

Please note that the Pharmacy Management bulletin also includes other drug formulary updates that have taken effect or will take effect soon. They apply to specialty drugs, topical corticosteroids, and some requirements for prior authorization, step therapy and quantity limits.

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Reeve Conover is a Registered Representative. Securities offered through Cambridge Investment Research, Inc., a Broker/dealer member FINRA/SPIC. Cambridge and Conover Consulting are not affiliated. Licensed in SC, NC, NY, CT, NJ, and CA.
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