Relates to prescription drugs in Medicaid managed care programs; repealers

BILL NUMBER:S7894

Title of bill

An act to amend the social services law and the public health law, in relation to prescription drugs in Medicaid managed care programs; and to repeal certain provisions of the social services law, relating to payments for prescription drugs

Purpose

To restore the "prescriber prevails" principle for all drugs, and other basic consumer protections, to prescription drug coverage under Medicaid managed care and add it to Family Health Plus and Child Health Plus.

Summary of provisions

This bill requires Medicaid managed care, Family Health Plus, and Child Health Plus plans to adopt the procedural protections of the Preferred Drug Program, including "prescriber prevails," for all drugs. If a Medi- caid managed care plan chooses not to do so, prescription drugs will be carved out of that plan and covered on a fee-for-service basis. Plans may also contract with the Department of Health to use the Department's PDP to carry out these functions.

Justification

In 2005, when Medicaid prescription drug coverage was administered directly, by Medicaid, rather than being contracted out to managed care plans, the Preferred Drug Program (PDP) was established to shift prescribing to "preferred" drugs: (a) drugs that are significantly better than others in their therapeutic class and (b) other drugs in the class whose manufacturers pay the state higher rebates, The PDP included a range of procedures to protect prescribers and patients, including the rule that if, after consulting with the program, a prescriber still insists on prescribing a "non-preferred" drug, the prescriber's judgment prevails and the prescription is approved. The PDP was quite effective at shifting prescribing to the preferred drugs, while also protecting prescriber judgments on behalf of their patients. It is a model of how to effectively organize health care. However, in 2011 the Legislature went along with the Governor's budget proposal to have Medicaid managed care plans take over the prescription drug benefit. "Prescriber prevails" was included only for atypical anti psychotics and a small list of other drug classes.

In the 2013-14 enacted budget, "prescriber prevails" was protected and expanded for some categories of drugs. This bill restores the "prescri- ber prevails" principle for all drugs and other basic consumer protections for prescription drug coverage under Medicaid managed care, and adds it to Family Health Plus and Child Health Plus.

Legislative history

New Bill.

Fiscal implications

Minimal.

Effective date

This act shall take effect on the one hundred eightieth day after it shall become a law; provided, however, that section two of this act shall take effect one year after this act shall become a law; and provided further, that the amendments to section 369-ee of the social services law made by section three of this act shall not affect the repeal of such section and shall be deemed to expire therewith and provided further, that the commissioner of health is immediately author- ized and directed to take actions necessary to implement this act when it takes effect.