What's happening
This bill expands mandatory Medicaid managed care coverage for certain prescription drug classes and strengthens prescriber authority in determining medical necessity.
Why it matters
Expands the list of protected drug classes. The bill adds new classes (endocrine, hematologic, immunologic) to the list of prescription drugs that Medicaid managed care plans must cover, which could improve access for patients with conditions like diabetes, blood disorders, and immune diseases.
Strengthens prescriber authority. Prescribers’ professional judgment about what drug is medically necessary will generally be final, limiting managed care organizations’ power to override these decisions—potentially speeding up patient access to needed medications.
Includes exceptions to prescriber authority. The bill makes clear that prescribers’ decisions are not final if the managed care plan covers a generic drug (and state law mandates generic substitution), or if the prescribed use is not FDA-approved or recognized by major drug reference compendia—balancing clinical autonomy with cost controls and patient safety.
Removes prior restrictions. By repealing a previous section (subdivision 25-a), the legislation eliminates potentially conflicting or restrictive provisions, streamlining the law and possibly reducing administrative barriers for both patients and providers.
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Who cares
Headline styles
Expand Medicaid Drug Coverage
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Referred to health
- Print number 1794a
- Amend and recommit 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 Assembly Committee · Ways And Means · Sponsor Richard Gottfried
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
1794--A
2019-2020 Regular Sessions
IN SENATE
January 16, 2019
Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Health -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee
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 title (mandatory generic substitution), and even if 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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03448-05-9
S. 1794--A 2
Service (AHFS), the DRUGDEX Drug Information System and the United States Pharmacopeia.
§ 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 road- blocks. 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 2017-2018: S 6541 Hannon
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.