What's happening
This bill requires managed care providers to cover certain prescription drugs if a prescriber determines they are medically necessary, making that determination final with limited exceptions.
Why it matters
Strengthens prescriber authority. The bill gives the final say to a patient’s prescriber (such as their doctor) about whether certain drugs are medically necessary, limiting managed care plans’ ability to deny coverage for these prescriptions—except in narrowly defined circumstances.
Expands drug classes protected. The list of drugs covered under these rules now explicitly includes not just anti-depressants and atypical antipsychotics, but also anti-retrovirals, antirejection, seizure, epilepsy, endocrine, hematologic, and immunologic drugs, which are often prescribed for complex or chronic conditions.
Limits exceptions for denial. Managed care plans can only override the prescriber’s determination if the drug is for “off-label” use not supported by the FDA or official reference sources, or if there’s a generic substitution requirement that the prescriber hasn’t exempted.
Potential impact on patient access and costs. By reducing managed care interference in drug choices, patients may gain faster and more reliable access to needed medications, though it could also affect how plans manage costs and utilization of expensive or specialized drugs.
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Who cares
Headline styles
Expand Medicaid Drug Coverage
Plain English, a few words. Used as the page title.
Sponsors
2 Co-sponsors
History
- Referred to rules
- Delivered to senate
- Passed assembly
- Advanced to third reading cal.982
- Reported
- Referred to ways and means
- Reported referred to ways and means
- Referred to health
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Expand Medicaid Drug Access
In Senate Committee · Health · Sponsor Kemp Hannon
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
4007
2017-2018 Regular Sessions
IN ASSEMBLY
January 30, 2017
Introduced by M. of A. GOTTFRIED -- read once and referred to the Committee on Health
AN ACT to amend the social services law, in relation to coverage for certain prescription drugs; and to repeal certain provisions of such law relating thereto
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subdivision 25 of section 364-j of the social services law, as added by section 55 of part D of chapter 56 of the laws of 2012, is amended to read as follows:
25. [Effective January first, two thousand thirteen, notwithstanding] Notwithstanding any provision of law to the contrary, managed care providers shall cover medically necessary prescription drugs in the anti-depressant, anti-retroviral, antirejection, seizure, epilepsy, endocrine, hematologic, immunologic and atypical antipsychotic therapeutic [class] classes, including non-formulary drugs, upon [demonstration] determination by the prescriber under this subdivision. If the prescriber, after consulting with the managed care provider, determines that such drugs, in the prescriber's reasonable professional judgment, are medically necessary and warranted, the prescriber's determination shall be final. However, the prescriber's determination shall not be final: (a) where the drug approved by the managed care provider is a generic drug subject to subparagraph (i) of paragraph (a-1) of subdivision four of section three hundred sixty-five-a of this article (mandatory generic substitution), and the prescriber has indicated that the prescription shall be dispensed as written; or (b) if it is for the use of a drug that is not consistent with food and drug administration-approved labeling or supported by one or more official Compendia references, including, but not limited to, the American Hospital Formulary Service (AHFS), the DRUGDEX Drug Information System and the United States Pharmacopeia.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07092-02-7
A. 4007 2
§ 2. Subdivision 25-a of section 364-j of the social services law is REPEALED.
§ 3. This act shall take effect on the sixtieth day after it shall have become a law; provided that effective immediately, the commissioner of health may make regulations and take other actions necessary to implement this act on that date; and provided, further, that the amendments to 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.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.