Eliminates the requirement that prescription drugs covered by a managed care provider be in the atypical antipsychotic therapeutic class

BILL NUMBER:S7325A

Title of bill

An act to amend the social services law, in relation to managed care provider coverage of medically necessary prescription drugs

Purpose

This bill would expand "prescriber prevails" protections within Medicaid managed care to individuals with a life threatening or disabling condition or disease

Summary of provisions

The bill would revise Subdivision 25 of section 364-j of the social services law, which currently provides for prescriber prevails protections related to atypical antipsychotics, to provide this critical protection for all individuals who receive Medicaid.

Justification

The 2011-12 New York State Budget, as part of a comprehensive redesign of the Medicaid program, moved the overwhelming majority of prescription drug coverage from the Medicaid fee-for-service program into Medicaid Managed Care. With this shift, certain patient protections which were historically available to Medicaid enrollees were lost. Most notably, a provision referred to as "prescriber prevails" still exists in fee-for-service but was not applied to Medicaid Managed Care in the initial shift, or "carve-in", of the benefit.

After the carve in of the prescription drug benefit became effective on October 1, 2011, it became apparent that some Medicaid enrollees were having challenges accessing critical medications. Advocates for New York's most vulnerable populations have continually raised this concern and have argued that the final determination regarding which medication is appropriate for a patient should lie with his or her health care provider.

In response to this concern, efforts to remedy the problem and restore prescriber prevails culminated in the Partial reinstatement of this protection in the 2012-13 budget. Specifically, a provider will prevail with respect to a medication in the atypical antipsychotic class when in his reasonable medical judgment he believes the prescribed medication is medically necessary. While this provision restores critical protection for one segment of New York's Medicaid population, it ignores an identical need in a broader universe of patients suffering from a whole host of life threatening or disabling conditions.

The purpose of this bill is to simply extend the critical protection of prescriber prevails beyond just those Medicaid enrollees requiring atypical antipsychotics to all Medicaid enrollees.

Legislative history

New Bill.

Fiscal implications

To be determined.

Effective date

This act shall take effect on the same date and in the same manner as section 55 of part D of chapter 56 of the laws of 2012, takes effect; provided, however that the amendments to subdivision 25 of section 364-j of the social services law made by section one of this act shall not affect the repeal of such section and shall be deemed repealed therewith.