What's happening
This bill requires managed care providers to cover certain prescription drugs based on a prescriber's determination of medical necessity, with limited exceptions.
Why it matters
Shifts decision-making authority. The bill gives prescribers, rather than managed care providers, the final say on the medical necessity of certain critical prescription drugs (such as antidepressants, antiretrovirals, antirejection, seizure, epilepsy, endocrine, hematologic, immunologic, and atypical antipsychotic medications), unless specific exceptions apply. This could reduce insurance denials and delays for patients requiring these medications.
Limits on insurer overrides. Managed care plans are generally required to honor the prescriber's judgment, except when a generic substitution is mandated by law (unless the prescriber insists on "dispense as written"), or when the drug is not FDA-approved or backed by recognized medical compendia. This creates clear boundaries on when insurers can deny coverage, potentially increasing transparency and predictability for patients and providers.
Potential to improve continuity of care. By ensuring patients can access the specific medications their doctors deem necessary, the bill may help avoid treatment disruptions, adverse events from forced medication switches, or administrative burdens on healthcare providers and patients fighting coverage denials.
Repeals prior related provisions. The bill repeals a subdivision of the law related to this topic, potentially streamlining or clarifying the legal framework for prescription drug coverage decisions in managed care, which could reduce confusion or conflicting requirements.
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Who cares
Headline styles
Expand Medicaid Drug Access
Plain English, a few words. Used as the page title.
Sponsors
1 Co-sponsor
History
- Referred to health
- 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 Coverage
In Senate Committee · Rules · Sponsor Richard Gottfried
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
6541
2017-2018 Regular Sessions
IN SENATE
June 1, 2017
Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed 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
S. 6541 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.
Sponsor's memo
Title of bill
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
Purpose
:
To clarify that "prescriber prevails" provisions under Medicaid managed care for certain classes of drugs shall be conducted as it currently is for fee-for-service Medicaid recipients, with exceptions.
Summary of provisions
:
Section 1 of the bill Amends Social Services Law § 364-j, subdivision 25 to obligate a Medicaid managed care plan to cover a drug benefit when, in the prescriber's reasonable professional judgment, the prescription is medically necessary and warranted. The exceptions are in the instance when a drug is required by the Medicaid program to be filled with a generic substitute and the prescriber has marked "dispense as written;" or when the prescription is related to a use not supported by the FDA-approved label, or official compendia or formularies. The bill also consolidates into subdivision 25 the drug classes listed in subdivision 25-a, and repeals subdivision 25-a.
Justification
:
Current law allows physicians treating patients under the Medicaid fee-for-service program to invoke prescriber prevails without extra roadblocks. This bill will ensure that a managed-care Medicaid patient's health care professional has the final say in determining which drug, in certain classes, will be dispensed to the patient unless the drug requires generic substitution, or the intended purpose is off-label or not supported by official compendia. This bill is drafted to respond to the veto message that was issued by the Governor in relation to the 2015 bill.
Legislative history
:
Similar to S 4893 of 2015 which was vetoed
Fiscal implications
:
To be determined
Effective date
:
On the 60th day after enactment, provided that effective immediately the Commissioner of health may make regulations necessary to implement the act.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.