Requires medical assistance managed care providers to provide coverage for medically necessary prescription drugs and medical supplies

Summary of specific provisions

Section one amends subdivision 1 of section 364-j of the social services law to define "pharmacy and therapeutics committee" as an independent committee used by managed care providers to develop and manage a formulary or preferred drug list that operate pursuant to the requirements of subdivision 25 of this section.

Section 2 adds two new subdivisions 25 and 26 to section 364-j of the Social Services law. Subdivision 25 requires Medicaid Managed Care plans to institute basic patient protections to ensure that formulary or prescription drug lists are developed by independent individuals with appropriate clinical experience.

Subdivision 26 requires the department of health to prepare a report that would include: 1) the impact of managed care on patient access to care; 2) evaluation of any barriers to use care services; 3) the impact of the managed care expansion on utilization of services; and 4) the use of prior authorization and other utilization management tool. The report shall be submitted to the Governor and the Legislature. This section also requires the Department of Health to develop a report reviewing the impact of changes to the Medicaid pharmacy benefit.

Section three states that this act shall take effect immediately. However, amendments to section 364-j of the social services law made by sections one and two of this act shall not affect the repeal of such section and shall be deemed repealed therewith.

Existing law

Existing law does not prescribe specific statutory protections for Medicaid Managed Care members with regard to access to necessary prescription drugs primarily because, prior to this year, the prescription drug benefit was "carved out" of Medicaid Manage Care and instead was included as a fee for service benefit. The 2011-12 State Budget "carved in" the pharmacy benefit from fee-for-service to Medicaid managed care necessitating the need for this legislation.

Justification

Since the development of the Prescription Drug Program ("PDP") in 2005, Medicaid beneficiaries have benefited from a number patient protections designed to ensure access to appropriate medication including having Clinical experts on the Pharmacy and Therapeutics

Committee ("P&T") who oversee development of the Prescription Drug List ("PDL).

With the enactment of the 2011-12 Budget, the pharmacy benefit was largely moved from the fee-for-service Medicaid program to Medicaid Managed Care ("MMC"), without carrying forward many of the protections for Medicaid patients such as the P&T Committee and "prescriber prevails".

Delaying patient access to medicines denies care. Patients and their providers need open access to medications in order to maintain consistent disease management. Disrupting continuity of care can result in detrimental life threatening consequences to the individuals who are the most vulnerable and can actually lead to more medical complications and higher health care costs.

Basing decisions for inclusion on a formulary or preferred drug list on cost rather than clinical considerations, ignores important variations that can exist among patients in terms of safety, efficacy, and tolerability in drug classes. New scientific research shows there are gender, racial, and ethnic differences in responses to treatments, and limiting access will greatly widen already existing health disparities.

This legislation is designed to carry critical fee-for-service patient protections into MMC to ensure Medicaid beneficiaries, among New York's most vulnerable population, have appropriate access to medically necessary medications regardless of which aspect of the program is managing their drug benefit.

Limiting access to vital life-saving medications will disrupt continuity of care and result in driving up the cost of Medicaid in the long run by increasing the number of unnecessary hospitalizations and emergency room visits. Since the vast majority of Medicaid enrollees in New York State are children, blind/disabled, and elderly; and more than 50% are people of color, limitations to treatment will disproportionately affect access to vital health care for the most vulnerable populations.

Prior legislative history

New Bill.

Fiscal implications

Medicaid Managed Care Plans are still afforded the ability to manage the benefit and generate rebates for the State. Likewise, the State can continue to accrue the projected savings through the Medicaid rate approval process. Proper medication prescription according to professional specialist doctor recommendations will reduce the hospitalizations and therefore possibly result in significant savings.

Effective date

This act shall take effect immediately. However, amendments to section 364-j of the social services law made by sections one and two of this act shall not affect the repeal of such section and shall be deemed repealed therewith.