Provides that drug utilization review and the preferred drug program shall not apply to certain drugs

BILL NUMBER:A9009

Title of bill

An act to amend the social services law and the public health law, in relation to drug utilization review and the preferred drug program

Purpose

To ensure new Medicaid prescription drug utilization controls maintain existing protections.

Summary of provisions

Section one ensures existing carve-outs apply to new step therapy provisions. Current law already includes provider-pre- vails language.

Section two ensures existing provider-prevails protections and carve- outs apply to new use, frequency and duration utilization controls.

Section three ensures existing provider-prevails protections and carve- outs apply to directly-negotiated agreements with manufacturers.

Section four establishes the effective date.

Existing law

The SPY 2009-10 budget included various new mechanisms intended to control prescription drug costs in New York's Medicaid program. It is unclear, however, if these new provisions are subject to existing protections found in the Prescription Drug Program.

Justification

New York's Prescription Drug Program (PDP) contains two important protections for consumers. Certain drugs (anti-psychotics, anti-retrovirals, anti-depressants, and anti-rejection medications) are excluded, or "carved out", entirely from the PDP. Additionally, all drugs which are included in the PDP may still be accessed by Medicaid beneficiaries if their provider determines the drug in question is warranted in his or her professional judgment.

The SPY 2009-10 gave the Drug Utilization Review Board the authority to establish a step therapy program as well as controls on the use, frequency and-duration of certain drugs. While the budget clearly indi- cated that the PDP prior authorization approach, including provider prevails, applies to step therapy, there is no clear indication that provider prevails applies to use, frequency and duration controls or that currently carved-out drugs would be excluded from controls devel- oped under either program. This bill clarifies that these existing protections apply to new utilization control programs developed by the Board.

The budget also allowed the Department of Health to negotiate directly with drug manufacturers to establish supplemental rebates, This bill clarifies that provider prevails and carve-out protections will apply to such agreements.

Legislative history

New Bill

Fiscal implications

None

Local fiscal implications

None

Effective date

September 1, 2009