Senate Bill S7325

                                BILL NUMBER:S7325A

TITLE OF BILL:
An act
to amend the social services law, in relation to managed care provider
coverage of medically necessary prescription drugs

PURPOSE:
This bill would expand "prescriber prevails" protections within
Medicaid managed care to individuals with a life threatening or
disabling condition or disease

SUMMARY OF PROVISIONS:
The bill would revise Subdivision 25 of section 364-j of the social
services law, which currently provides for prescriber prevails
protections related to atypical antipsychotics, to provide this
critical protection for all individuals who receive Medicaid.

JUSTIFICATION:
The 2011-12 New York State Budget, as part of a comprehensive redesign
of the Medicaid program, moved the overwhelming majority of
prescription drug coverage from the Medicaid fee-for-service program
into Medicaid Managed Care. With this shift, certain patient
protections which were historically available to Medicaid enrollees
were lost. Most notably, a provision referred to as "prescriber
prevails" still exists in fee-for-service but was not applied to
              

Medicaid Managed Care in the initial shift, or "carve-in", of the
benefit.

After the carve in of the prescription drug benefit became effective
on October 1, 2011, it became apparent that some Medicaid enrollees
were having challenges accessing critical medications. Advocates for
New York's most vulnerable populations have continually raised this
concern and have argued that the final determination regarding which
medication is appropriate for a patient should lie with his or her
health care provider.

In response to this concern, efforts to remedy the problem and restore
prescriber prevails culminated in the Partial reinstatement of this
protection in the 2012-13 budget. Specifically, a provider will
prevail with respect to a medication in the atypical antipsychotic
class when in his reasonable medical judgment he believes the
prescribed medication is medically necessary.
While this provision restores critical protection for one segment of
New York's Medicaid population, it ignores an identical need in a
broader universe of patients suffering from a whole host of life
threatening or disabling conditions.

The purpose of this bill is to simply extend the critical protection
of prescriber prevails beyond just those Medicaid enrollees requiring
atypical antipsychotics to all Medicaid enrollees.

LEGISLATIVE HISTORY:
New Bill.

FISCAL IMPLICATIONS:
To be determined.

EFFECTIVE DATE:
This act shall take effect on the same date and in the same
manner as section 55 of part D of chapter 56 of the laws of
2012, takes effect; provided, however that the amendments to
subdivision 25 of 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.