How low is the NY WC Rx fee schedule?
New York's new fee schedule for drugs dispensed to workers comp claimants is among the lowest in the nation.
How low?
Multiple-source drugs with a Federal Upper Limit: at FUL
Multiple-source drugs with no FUL: lower of Estimated Acquisition Cost (EAC) or pharmacy's usual/customer charge.
EAC for branded drugs = AWP less 13.25%
EAC for generics = AWP less 20%
If there is no FUL, NY Medicaid is authorized to establish a maximum acquisition cost.
(NY Social Service Law ยง 367-a.)
PBMs will be hardpressed to make any money on brands, but may do OK on generics. Remember, most drugs dispensed for workers comp are generics.
But that is not the case for brands. I would expect that payers will be asked to pay PBMs an admin fee for handling brand drugs, an admin fee that will make this at least a break-even for PBMs. There is precedence here; when California implemented their own fee schedule change, many payers recognized that the pricing was insufficient to keep PBMs in the market and agreed to pay a surcharge to their PBM for CA scripts.
And no, there is no evidence that somehow PBMs were getting money under the table in CA, and it isn't going to happen in NY either. For a very simple reason - there is no money to give.
Comments
Joe,
What happens come Jan when AMP is in effect? Won't it be harder for the PBM's or anyone, to make money on generics?
Posted by: George | July 18, 2007 12:06 PM