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News & Press: Legislative & Regulatory

Emergency Rule: Pharmacy Benefits Formulary

Friday, October 3, 2014   (0 Comments)
Posted by: Tijonne Edmond
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The following Emergency Rule was released on October 2, 2014:

Prior Authorization Requirements, Benefit Limits, Pharmacy Benefits Formulary (LAC 32:I.1701)

  • Released by the Office of the Governor, Division of Administration, Office of Group Benefits
  • Effective September 30, 2014
  • The Office of Group Benefits (OGB), to protect the public’s health, safety, and welfare, must at times amend certain General Provisions including those relative to prior authorization requirements, benefit limits, and pharmacy benefits.  Current law does not require promulgation for such amendments of rules to occur.  However, OGB is promulgating this rule due to the high risk of financial exposure of the state, OGB, plan enrollees, and other state programs as a result of possible legal action requiring the promulgation of such rules.
  • The effective rule is to address the imminent peril to the OGB fund balance which, in its current state, will become actuarially unsound and unstable. Should the fund experience a deficit, taxpayers would statutorily be required to pay the costs of any increase in premiums to enrollees.  Such an action would place other state programs in jeopardy of budget cuts.
  • Relative to the Pharmacy Benefits Formulary, OGB shall have discretion to adopt its PBM pharmacy benefits formulary or other drug formulary, either of which will be reviewed quarterly to reassess drug tiers.  Enrollees’ obligatory payment will be based on whether medications are generic, preferred brand, non-preferred brand, or specialty. Formulary changes for Medicare patients shall be effective January 1, 2015.  90-day prescriptions for maintenance medication may be filled at retail pharmacies for two and a half times the cost of the co-pay. Medications with equivalent strength over-the-counter alternatives will no longer be covered by the pharmacy plan.  The pharmacy co-payment threshold is changed from $1,200 - $1,500.  See the complete rule for additional threshold changes, as well as updated information relative to drug utilization management.
  • View the Emergency Rule.

 


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