NY State Senate Bill 2019-S1794A

Senate Bill S1794A

2019-2020 Legislative Session

Relates to coverage for certain prescription drugs in Medicaid managed care programs; repealer

download bill text pdf

Archive: Last Bill Status - In Senate Committee Health Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

Please enter your contact information

First Name

Last Name

Email Address

A valid email address is required.

Home address is used to determine the senate district in which you reside. Your support or opposition to this bill is then shared immediately with the senator who represents you.

Optional services from the NY State Senate:

Create an account. An account allows you to officially support or oppose key legislation, sign petitions with a single click, and follow issues, committees, and bills that matter to you. When you create an account, you agree to this platform's terms of participation.

Include a custom message for your Senator? (Optional)

Enter a message to your senator. Many New Yorkers use this to share the reasoning behind their support or opposition to the bill. Others might share a personal anecdote about how the bill would affect them or people they care about.

Actions

View Actions

	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 08, 2020	referred to health
Feb 26, 2019	print number 1794a
Feb 26, 2019	amend and recommit to health
Jan 16, 2019	referred to health

Bill Amendments

Original

A (Active)

2019-S1794 - Details

See Assembly Version of this Bill:: A2799
Current Committee:: Senate Health
Law Section:: Social Services Law
Laws Affected:: Amd §364-j, rpld sub 25-a, Soc Serv L
Versions Introduced in Other Legislative Sessions:: 2017-2018: S6541, A4007
2021-2022: S1588
2023-2024: S503

2019-S1794 - Summary

Provides for coverage for certain medically necessary prescription drugs in Medicaid managed care programs.

2019-S1794 - Sponsor Memo

                                
 
BILL NUMBER: S1794

SPONSOR: RIVERA
 
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
feefor-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

 
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.

2019-S1794 - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1794
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                             January 16, 2019
                                ___________
 
 Introduced  by  Sen.  RIVERA -- 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  ASSEM-
 BLY, 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 therapeu-
 tic [class] CLASSES, including non-formulary drugs, upon [demonstration]
 DETERMINATION by THE PRESCRIBER UNDER THIS SUBDIVISION. IF the  prescri-
 ber,  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 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 LABEL-
 ING OR SUPPORTED BY ONE OR MORE OFFICIAL COMPENDIA  REFERENCES,  INCLUD-
 ING, 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.
                                                            LBD03448-02-9

 S. 1794                             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 amend-
 ments 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.

2019-S1794A (ACTIVE) - Details

See Assembly Version of this Bill:: A2799
Current Committee:: Senate Health
Law Section:: Social Services Law
Laws Affected:: Amd §364-j, rpld sub 25-a, Soc Serv L
Versions Introduced in Other Legislative Sessions:: 2017-2018: S6541, A4007
2021-2022: S1588
2023-2024: S503

2019-S1794A (ACTIVE) - Summary

Provides for coverage for certain medically necessary prescription drugs in Medicaid managed care programs.

2019-S1794A (ACTIVE) - Sponsor Memo

                                
 
BILL NUMBER: S1794A

SPONSOR: RIVERA
 
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.

2019-S1794A (ACTIVE) - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  1794--A
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                             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 ASSEM-
 BLY, 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 therapeu-
 tic [class] CLASSES, including non-formulary drugs, upon [demonstration]
 DETERMINATION  by THE PRESCRIBER UNDER THIS SUBDIVISION. IF the prescri-
 ber, 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-AP-
 PROVED LABELING OR SUPPORTED BY ONE OR MORE  OFFICIAL  COMPENDIA  REFER-
 ENCES,  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  amend-
 ments 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.

Comments

Open Legislation is a forum for New York State legislation. All comments are subject to review and community moderation is encouraged.

Comments deemed off-topic, commercial, campaign-related, self-promotional; or that contain profanity, hate or toxic speech; or that link to sites outside of the nysenate.gov domain are not permitted, and will not be published. Attempts to intimidate and silence contributors or deliberately deceive the public, including excessive or extraneous posting/posts, or coordinated activity, are prohibited and may result in the temporary or permanent banning of the user. Comment moderation is generally performed Monday through Friday. By contributing or voting you agree to the Terms of Participation and verify you are over 13.

Create an account. An account allows you to sign petitions with a single click, officially support or oppose key legislation, and follow issues, committees, and bills that matter to you. When you create an account, you agree to this platform's terms of participation.