S T A T E O F N E W Y O R K
________________________________________________________________________
2335--B
2013-2014 Regular Sessions
I N A S S E M B L Y
January 14, 2013
___________
Introduced by M. of A. RODRIGUEZ, ABINANTI, GUNTHER, BRONSON, RIVERA,
CYMBROWITZ, BROOK-KRASNY, GOTTFRIED, JACOBS, MAISEL, SCHIMEL, BOYLAND,
ARROYO, JAFFEE, PERRY, SCARBOROUGH, WEPRIN, DINOWITZ, CAMARA, GOLDFED-
ER, GIBSON, ROSENTHAL, COLTON, HOOPER, ZEBROWSKI, SIMANOWITZ, MAGNAR-
ELLI, BENEDETTO, ABBATE, AUBRY, TITONE, GABRYSZAK, ROBERTS, CRESPO,
ESPINAL, QUART, BARRON, WEISENBERG, CAHILL, MILLMAN, SKOUFIS, OTIS,
RAIA -- Multi-Sponsored by -- M. of A. BRENNAN, CLARK, COOK, CROUCH,
DUPREY, GLICK, HEASTIE, LENTOL, LUPARDO, MAGEE, PEOPLES-STOKES,
RUSSELL, SKARTADOS, SWEENEY, THIELE, TITUS, WEINSTEIN, WRIGHT -- read
once and referred to the Committee on Health -- reported and referred
to the Committee on Codes -- reported and referred to the Committee on
Ways and Means -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee -- again
reported from said committee with amendments, ordered reprinted as
amended and recommitted to said committee
AN ACT to amend the social services law and the public health law, in
relation to prescription drugs in Medicaid managed care programs; and
to repeal certain provisions of the social services law, relating to
payments for prescription drugs
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. The social services law is amended by adding a new section
365-i to read as follows:
S 365-I. PRESCRIPTION DRUGS IN MEDICAID MANAGED CARE PROGRAMS. 1.
DEFINITIONS. AS USED IN THIS SECTION, UNLESS THE CONTEXT CLEARLY
REQUIRES OTHERWISE:
(A) "ARTICLE" MEANS TITLE ELEVEN OF ARTICLE FIVE OF THIS CHAPTER WITH
RESPECT TO THE MEDICAL ASSISTANCE PROGRAM, TITLE ELEVEN-D OF ARTICLE
FIVE OF THIS CHAPTER WITH RESPECT TO THE FAMILY HEALTH PLUS PROGRAM, AND
TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THE PUBLIC HEALTH LAW WITH RESPECT
TO THE CHILD HEALTH INSURANCE PROGRAM.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD05620-03-3
A. 2335--B 2
(B) "CLINICAL DRUG REVIEW PROGRAM" MEANS THE CLINICAL DRUG REVIEW
PROGRAM UNDER SECTION TWO HUNDRED SEVENTY-FOUR OF THE PUBLIC HEALTH LAW.
(C) "EMERGENCY CONDITION" MEANS A MEDICAL OR BEHAVIORAL CONDITION AS
DETERMINED BY THE PRESCRIBER OR PHARMACIST, THE ONSET OF WHICH IS
SUDDEN, THAT MANIFESTS ITSELF BY SYMPTOMS OF SUFFICIENT SEVERITY,
INCLUDING SEVERE PAIN, AND FOR WHICH DELAY IN BEGINNING TREATMENT
PRESCRIBED BY THE PATIENT'S HEALTH CARE PRACTITIONER WOULD RESULT IN:
(I) PLACING THE HEALTH OR SAFETY OF THE PERSON AFFLICTED WITH SUCH
CONDITION OR OTHER PERSON OR PERSONS IN SERIOUS JEOPARDY;
(II) SERIOUS IMPAIRMENT TO SUCH PERSON'S BODILY FUNCTIONS;
(III) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART OF SUCH PERSON;
(IV) SERIOUS DISFIGUREMENT OF SUCH PERSON; OR
(V) SEVERE DISCOMFORT.
(D) "MANAGED CARE PROVIDER" MEANS A MANAGED CARE PROVIDER UNDER
SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE, A MANAGED LONG TERM
CARE PLAN OR OTHER CARE COORDINATION MODEL UNDER SECTION FORTY-FOUR
HUNDRED THREE-F OF THE PUBLIC HEALTH LAW, A FAMILY HEALTH INSURANCE PLAN
UNDER SECTION THREE HUNDRED SIXTY-NINE-EE OF THIS ARTICLE OR AN EMPLOYER
PARTNERSHIP FOR FAMILY HEALTH PLUS PLAN UNDER SECTION THREE HUNDRED
SIXTY-NINE-FF OF THIS ARTICLE (FAMILY HEALTH PLUS PROGRAM), AN APPROVED
ORGANIZATION UNDER TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THE PUBLIC
HEALTH LAW (CHILD HEALTH INSURANCE PROGRAM), OR ANY OTHER ENTITY THAT
PROVIDES OR ARRANGES FOR THE PROVISION OF MEDICAL ASSISTANCE SERVICES
AND SUPPLIES TO PARTICIPANTS DIRECTLY OR INDIRECTLY (INCLUDING BY REFER-
RAL), INCLUDING CASE MANAGEMENT, INCLUDING THE MANAGED CARE PROVIDER'S
AUTHORIZED AGENTS.
(E) "NON-PREFERRED DRUG" MEANS A PRESCRIPTION DRUG THAT REQUIRES PRIOR
AUTHORIZATION UNDER THE PARTICIPANT'S MANAGED CARE PROVIDER.
(F) "PARTICIPANT" MEANS A MEDICAL ASSISTANCE RECIPIENT WHO RECEIVES,
IS REQUIRED TO RECEIVE OR ELECTS TO RECEIVE HIS OR HER MEDICAL ASSIST-
ANCE SERVICES FROM A MANAGED CARE PROVIDER.
(G) "PREFERRED DRUG" MEANS A PRESCRIPTION DRUG THAT IS NOT A NON-PRE-
FERRED DRUG UNDER THE PATIENT'S MANAGED CARE PROVIDER. "PREFERRED DRUG
LIST" MEANS A LIST OF A MANAGED CARE PROVIDER'S PREFERRED DRUGS.
(H) "PREFERRED DRUG PROGRAM" MEANS THE PREFERRED DRUG PROGRAM ESTAB-
LISHED UNDER SECTION TWO HUNDRED SEVENTY-TWO OF THE PUBLIC HEALTH LAW.
(I) "PRESCRIBER" MEANS A HEALTH CARE PROFESSIONAL AUTHORIZED TO
PRESCRIBE PRESCRIPTION DRUGS FOR A PARTICIPANT OF THE MANAGED CARE
PROVIDER, ACTING WITHIN HIS OR HER LAWFUL SCOPE OF PRACTICE.
(J) "PRESCRIPTION DRUG" OR "DRUG" MEANS A DRUG DEFINED IN SUBDIVISION
SEVEN OF SECTION SIXTY-EIGHT HUNDRED TWO OF THE EDUCATION LAW, FOR WHICH
A PRESCRIPTION IS REQUIRED UNDER THE FEDERAL FOOD, DRUG AND COSMETIC
ACT. ANY DRUG THAT DOES NOT REQUIRE A PRESCRIPTION UNDER SUCH ACT, BUT
WHICH WOULD OTHERWISE BE ELIGIBLE FOR REIMBURSEMENT UNDER THIS ARTICLE
WHEN ORDERED BY A PRESCRIBER AND THE PRESCRIPTION IS SUBJECT TO THE
APPLICABLE PROVISIONS OF THIS ARTICLE AND PARAGRAPH (A) OF SUBDIVISION
FOUR OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THIS TITLE.
(K) "PRIOR AUTHORIZATION" MEANS A PROCESS REQUIRING THE PRESCRIBER OR
THE DISPENSER TO VERIFY WITH THE PARTICIPANT'S MANAGED CARE PROVIDER
THAT THE DRUG IS APPROPRIATE FOR THE NEEDS OF THE SPECIFIC PATIENT.
(L) "QUALIFIED PRESCRIPTION DRUG SYSTEM" OR "SYSTEM" MEANS A PROCESS
UNDER THIS SECTION, APPROVED BY THE COMMISSIONER, THROUGH WHICH A
MANAGED CARE PROVIDER APPROVES PAYMENT FOR A NON-PREFERRED DRUG FOR A
PARTICIPANT BASED ON PRIOR AUTHORIZATION.
2. PAYMENT FOR PRESCRIPTION DRUGS UNDER CAPITATION. (A) PAYMENT FOR
PRESCRIPTION DRUGS SHALL BE INCLUDED IN THE CAPITATION PAYMENTS FOR
A. 2335--B 3
SERVICES OR SUPPLIES PROVIDED TO A MANAGED CARE PROVIDER'S PARTICIPANTS,
PROVIDED THAT THE MANAGED CARE PROVIDER PAYS FOR PRESCRIPTION DRUGS
UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM. EVERY PRESCRIPTION DRUG
ELIGIBLE FOR REIMBURSEMENT UNDER THIS ARTICLE PRESCRIBED IN RELATION TO
A SERVICE PROVIDED BY THE MANAGED CARE PROVIDER SHALL BE EITHER A
PREFERRED OR NON-PREFERRED DRUG UNDER THE QUALIFIED PRESCRIPTION DRUG
SYSTEM. THE COMMISSIONER SHALL APPROVE A MANAGED CARE PROVIDER'S QUALI-
FIED PRESCRIPTION DRUG SYSTEM IF IT CONFORMS TO THE PROVISIONS OF THIS
SECTION.
(B) IF THE MANAGED CARE PROVIDER DOES NOT PAY FOR PRESCRIPTION DRUGS
UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM, THEN PAYMENT FOR
PRESCRIPTION DRUGS FOR THE MANAGED CARE PROVIDER'S PATIENTS SHALL NOT BE
INCLUDED IN SUCH CAPITATION PAYMENTS AND PRESCRIPTION DRUGS SHALL BE
PROVIDED FOR THE MANAGED CARE PROVIDER'S PARTICIPANTS UNDER THE
PREFERRED DRUG PROGRAM.
3. QUALIFIED PRESCRIPTION DRUG SYSTEM; CRITERIA. (A) A QUALIFIED
PRESCRIPTION DRUG SYSTEM SHALL PROMOTE ACCESS TO THE MOST EFFECTIVE
PRESCRIPTION DRUGS WHILE REDUCING THE COST OF PRESCRIPTION DRUGS UNDER
THIS ARTICLE. THIS SUBDIVISION AND SUBDIVISION FOUR OF THIS SECTION
APPLY TO QUALIFIED PRESCRIPTION DRUG SYSTEMS.
(B) WHEN A PRESCRIBER PRESCRIBES A NON-PREFERRED DRUG FOR A PARTIC-
IPANT, REIMBURSEMENT MAY BE DENIED UNLESS PRIOR AUTHORIZATION IS
OBTAINED, UNLESS NO PRIOR AUTHORIZATION IS REQUIRED UNDER THIS SECTION.
WHEN A PRESCRIBER PRESCRIBES A PREFERRED DRUG FOR A PARTICIPANT, NO
PRIOR AUTHORIZATION SHALL BE REQUIRED FOR REIMBURSEMENT, UNLESS PRIOR
AUTHORIZATION IS REQUIRED UNDER THE CLINICAL DRUG REVIEW PROGRAM.
(C) THE COMMISSIONER SHALL ESTABLISH PERFORMANCE STANDARDS FOR SYSTEMS
THAT, AT A MINIMUM, ENSURE THAT SYSTEMS PROVIDE SUFFICIENT TECHNICAL
SUPPORT AND TIMELY RESPONSES TO CONSUMERS, PRESCRIBERS AND PHARMACISTS.
(D) THE COMMISSIONER SHALL ADOPT CRITERIA FOR QUALIFIED PRESCRIPTION
DRUG SYSTEMS AFTER CONSIDERING RECOMMENDATIONS AND COMMENTS RECEIVED
FROM PRESCRIBERS, PHARMACISTS, PARTICIPANTS, AND ORGANIZATIONS REPRES-
ENTING THEM.
(E) THE MANAGED CARE PROVIDER SHALL DEVELOP ITS PREFERRED DRUG LIST
BASED INITIALLY ON AN EVALUATION OF THE CLINICAL EFFECTIVENESS, SAFETY,
AND PATIENT OUTCOMES, FOLLOWED BY CONSIDERATION OF THE COST-EFFECTIVE-
NESS OF THE DRUGS. IN EACH THERAPEUTIC CLASS, THE MANAGED CARE PROVIDER
SHALL DETERMINE WHETHER THERE IS ONE DRUG THAT IS SIGNIFICANTLY MORE
CLINICALLY EFFECTIVE AND SAFE, AND THAT DRUG SHALL BE INCLUDED ON THE
PREFERRED DRUG LIST WITHOUT CONSIDERATION OF COST. IF, AMONG TWO OR MORE
DRUGS IN A THERAPEUTIC CLASS, THE DIFFERENCE IN CLINICAL EFFECTIVENESS
AND SAFETY IS NOT CLINICALLY SIGNIFICANT, THEN COST-EFFECTIVENESS MAY
ALSO BE CONSIDERED IN DETERMINING WHICH DRUG OR DRUGS SHALL BE INCLUDED
ON THE PREFERRED DRUG LIST.
4. PRIOR AUTHORIZATION. (A) A QUALIFIED PRESCRIPTION DRUG SYSTEM SHALL
MAKE AVAILABLE A TWENTY-FOUR HOUR PER DAY, SEVEN DAYS PER WEEK TELEPHONE
CALL CENTER THAT INCLUDES A TOLLFREE TELEPHONE LINE AND DEDICATED
FACSIMILE LINE TO RESPOND TO REQUESTS FOR PRIOR AUTHORIZATION. THE CALL
CENTER SHALL INCLUDE QUALIFIED HEALTH CARE PROFESSIONALS WHO SHALL BE
AVAILABLE TO CONSULT WITH PRESCRIBERS CONCERNING PRESCRIPTION DRUGS THAT
ARE NON-PREFERRED DRUGS. A PRESCRIBER SEEKING PRIOR AUTHORIZATION SHALL
CONSULT WITH THE PROGRAM CALL LINE TO REASONABLY PRESENT HIS OR HER
JUSTIFICATION FOR THE PRESCRIPTION AND GIVE THE PROGRAM'S QUALIFIED
HEALTH CARE PROFESSIONAL A REASONABLE OPPORTUNITY TO RESPOND.
(B) WHEN A PATIENT'S HEALTH CARE PROVIDER PRESCRIBES A NON-PREFERRED
DRUG, THE PRESCRIBER SHALL CONSULT WITH THE SYSTEM TO CONFIRM THAT IN
A. 2335--B 4
HIS OR HER REASONABLE PROFESSIONAL JUDGMENT, THE PATIENT'S CLINICAL
CONDITION IS CONSISTENT WITH THE CRITERIA FOR APPROVAL OF THE NON-PRE-
FERRED DRUG. SUCH CRITERIA SHALL INCLUDE:
(I) THE PREFERRED DRUG HAS BEEN TRIED BY THE PATIENT AND HAS FAILED TO
PRODUCE THE DESIRED HEALTH OUTCOMES;
(II) THE PATIENT HAS TRIED THE PREFERRED DRUG AND HAS EXPERIENCED
UNACCEPTABLE SIDE EFFECTS;
(III) THE PATIENT HAS BEEN STABILIZED ON A NON-PREFERRED DRUG AND
TRANSITION TO THE PREFERRED DRUG WOULD BE MEDICALLY CONTRAINDICATED; OR
(IV) OTHER CLINICAL INDICATIONS IDENTIFIED BY THE COMMISSIONER OR THE
MANAGED CARE PROVIDER FOR THE PATIENT'S USE OF THE NON-PREFERRED DRUG,
WHICH SHALL INCLUDE CONSIDERATION OF THE MEDICAL NEEDS OF SPECIAL POPU-
LATIONS, INCLUDING CHILDREN, ELDERLY, CHRONICALLY ILL, PERSONS WITH
MENTAL HEALTH CONDITIONS, AND PERSONS AFFECTED BY HIV/AIDS OR HEPATITIS
C.
(C) IN THE EVENT THAT THE PATIENT DOES NOT MEET THE CRITERIA IN PARA-
GRAPH (B) OF THIS SUBDIVISION, THE PRESCRIBER MAY PROVIDE ADDITIONAL
INFORMATION TO THE MANAGED CARE PROVIDER TO JUSTIFY THE USE OF A
NON-PREFERRED DRUG. THE SYSTEM SHALL PROVIDE A REASONABLE OPPORTUNITY
FOR A PRESCRIBER TO REASONABLY PRESENT HIS OR HER JUSTIFICATION OF PRIOR
AUTHORIZATION. IF, AFTER CONSULTATION WITH THE MANAGED CARE PROVIDER,
THE PRESCRIBER, IN HIS OR HER REASONABLE PROFESSIONAL JUDGMENT, DETER-
MINES THAT THE USE OF A NON-PREFERRED DRUG IS WARRANTED, THE
PRESCRIBER'S DETERMINATION SHALL BE FINAL.
(D) IF A PRESCRIBER MEETS THE REQUIREMENTS OF PARAGRAPH (B) OR (C) OF
THIS SUBDIVISION, THE PRESCRIBER SHALL BE GRANTED PRIOR AUTHORIZATION
UNDER THIS SECTION.
(E) IN THE INSTANCE WHERE A PRIOR AUTHORIZATION DETERMINATION IS NOT
COMPLETED WITHIN TWENTY-FOUR HOURS OF THE ORIGINAL REQUEST, SOLELY AS
THE RESULT OF A FAILURE OF THE SYSTEM (WHETHER BY ACTION OR INACTION),
PRIOR AUTHORIZATION SHALL BE IMMEDIATELY AND AUTOMATICALLY GRANTED WITH
NO FURTHER ACTION BY THE PRESCRIBER AND THE PRESCRIBER SHALL BE NOTIFIED
OF THIS DETERMINATION. IN THE INSTANCE WHERE A PRIOR AUTHORIZATION
DETERMINATION IS NOT COMPLETED WITHIN TWENTY-FOUR HOURS OF THE ORIGINAL
REQUEST FOR ANY OTHER REASON, A SEVENTY-TWO HOUR SUPPLY OF THE MEDICA-
TION SHALL BE APPROVED BY THE SYSTEM AND THE PRESCRIBER SHALL BE NOTI-
FIED OF THIS DETERMINATION.
(F) WHEN, IN THE JUDGMENT OF THE PRESCRIBER OR THE PHARMACIST, AN
EMERGENCY CONDITION EXISTS, AND THE PRESCRIBER OR PHARMACIST NOTIFIES
THE MANAGED CARE PROVIDER THAT AN EMERGENCY CONDITION EXISTS, A SEVEN-
TY-TWO HOUR EMERGENCY SUPPLY OF THE DRUG PRESCRIBED SHALL BE IMMEDIATELY
AUTHORIZED BY THE MANAGED CARE PROVIDER.
(G) IN THE EVENT THAT A PATIENT PRESENTS A PRESCRIPTION TO A PHARMA-
CIST FOR A PRESCRIPTION DRUG THAT IS A NON-PREFERRED DRUG AND FOR WHICH
THE PRESCRIBER HAS NOT OBTAINED A PRIOR AUTHORIZATION, THE PHARMACIST
SHALL, WITHIN A PROMPT PERIOD BASED ON PROFESSIONAL JUDGMENT, NOTIFY THE
PRESCRIBER. THE PRESCRIBER SHALL, WITHIN A PROMPT PERIOD BASED ON
PROFESSIONAL JUDGMENT, EITHER SEEK PRIOR AUTHORIZATION OR SHALL CONTACT
THE PHARMACIST AND AMEND OR CANCEL THE PRESCRIPTION. THE PHARMACIST
SHALL, WITHIN A PROMPT PERIOD BASED ON PROFESSIONAL JUDGMENT, NOTIFY THE
PATIENT WHEN PRIOR AUTHORIZATION HAS BEEN OBTAINED OR DENIED OR WHEN THE
PRESCRIPTION HAS BEEN AMENDED OR CANCELLED.
(H) ONCE PRIOR AUTHORIZATION OF A PRESCRIPTION FOR A DRUG THAT IS NOT
ON THE PREFERRED DRUG LIST IS OBTAINED, PRIOR AUTHORIZATION SHALL NOT BE
REQUIRED FOR ANY REFILL OF THE PRESCRIPTION.
A. 2335--B 5
(I) NO PRIOR AUTHORIZATION UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM
SHALL BE REQUIRED FOR: (I) ATYPICAL ANTI-PSYCHOTICS; (II) ANTI-DEPRES-
SANTS; (III) ANTI-RETROVIRALS USED IN THE TREATMENT OF HIV/AIDS OR HEPA-
TITIS C; (IV) ANTI-REJECTION DRUGS USED IN THE TREATMENT OF ORGAN AND
TISSUE TRANSPLANTS; AND (V) ANY OTHER THERAPEUTIC CLASS FOR THE TREAT-
MENT OF MENTAL ILLNESS, HIV/AIDS OR HEPATITIS C, APPROVED BY THE COMMIS-
SIONER.
5. CLINICAL DRUG REVIEW PROGRAM. IN THE CASE OF A DRUG FOR WHICH PRIOR
AUTHORIZATION IS REQUIRED UNDER THE CLINICAL DRUG REVIEW PROGRAM, PRIOR
AUTHORIZATION SHALL BE OBTAINED UNDER THE CLINICAL DRUG REVIEW PROGRAM
AND NOT UNDER THIS SECTION.
6. PRESCRIBER CONDUCT. THE MANAGED CARE PROVIDER AND THE DEPARTMENT
SHALL MONITOR THE PRIOR AUTHORIZATION PROCESS UNDER A QUALIFIED
PRESCRIPTION DRUG SYSTEM FOR PRESCRIBING PATTERNS WHICH ARE SUSPECTED OF
ENDANGERING THE HEALTH AND SAFETY OF THE PATIENT OR WHICH DEMONSTRATE A
LIKELIHOOD OF FRAUD OR ABUSE. THE MANAGED CARE PROVIDER AND THE DEPART-
MENT SHALL TAKE ANY AND ALL ACTIONS OTHERWISE PERMITTED BY LAW TO INVES-
TIGATE SUCH PRESCRIBING PATTERNS, TO TAKE REMEDIAL ACTION AND TO ENFORCE
APPLICABLE FEDERAL AND STATE LAWS.
7. USE OF PREFERRED DRUG PROGRAM. THE COMMISSIONER MAY CONTRACT WITH A
MANAGED CARE PROVIDER FOR THE PROVIDER TO USE THE PREFERRED DRUG PROGRAM
TO PROVIDE PRIOR AUTHORIZATION UNDER THE MANAGED CARE PROVIDER'S QUALI-
FIED PRESCRIPTION DRUG SYSTEM. THE CONTRACT SHALL INCLUDE TERMS REQUIRED
BY THE COMMISSIONER TO MAXIMIZE SAVINGS TO THE MEDICAID PROGRAM AND
PROTECT THE HEALTH AND INTERESTS OF THE MANAGED CARE PROVIDER'S PARTIC-
IPANTS. THE CONTRACT SHALL PROVIDE WHETHER THE PREFERRED DRUG PROGRAM
SHALL USE THE MANAGED CARE PROVIDER'S LISTS OF PREFERRED AND NON-PRE-
FERRED DRUGS OR THE PREFERRED DRUG LIST UNDER THE PREFERRED DRUG
PROGRAM, WITH RESPECT TO WHETHER PRIOR AUTHORIZATION IS REQUIRED.
S 2. Subdivisions 25 and 25-a of section 364-j of the social services
law are REPEALED.
S 3. Subdivision 2-b of section 369-ee of the social services law is
REPEALED and a new subdivision 2-b is added to read as follows:
2-B. PAYMENT FOR PRESCRIPTION DRUGS. PAYMENT FOR PRESCRIPTION DRUGS
SHALL BE INCLUDED IN THE CAPITATED PAYMENTS FOR SERVICES OR SUPPLIES
PROVIDED UNDER A FAMILY HEALTH INSURANCE PLAN OR PROVIDED BY AN EMPLOYER
PARTNERSHIP FOR FAMILY HEALTH PLUS PLAN AUTHORIZED BY SECTION THREE
HUNDRED SIXTY-NINE-FF OF THIS TITLE, PROVIDED THAT THE PLAN PAYS FOR
PRESCRIPTION DRUGS UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM UNDER
SECTION THREE HUNDRED SIXTY-FIVE-I OF THIS ARTICLE. EVERY PRESCRIPTION
DRUG ELIGIBLE FOR REIMBURSEMENT UNDER THIS ARTICLE PRESCRIBED IN
RELATION TO A SERVICE PROVIDED BY THE PLAN SHALL BE EITHER A PREFERRED
OR NON-PREFERRED DRUG UNDER THE QUALIFIED PRESCRIPTION DRUG SYSTEM. IF
THE PLAN DOES NOT PAY FOR PRESCRIPTION DRUGS UNDER A QUALIFIED
PRESCRIPTION DRUG SYSTEM, THEN PAYMENT FOR PRESCRIPTION DRUGS FOR THE
PLAN'S PATIENTS SHALL NOT BE INCLUDED IN SUCH CAPITATION PAYMENTS AND
PRESCRIPTION DRUGS SHALL BE PROVIDED FOR THE APPROVED ORGANIZATION'S
PARTICIPANTS UNDER THE PREFERRED DRUG PROGRAM.
S 4. Section 2511 of the public health law is amended by adding a new
subdivision 22 to read as follows:
22. PAYMENT FOR PRESCRIPTION DRUGS. PAYMENT FOR PRESCRIPTION DRUGS
SHALL BE INCLUDED IN THE PAYMENTS FOR SERVICES OR SUPPLIES PROVIDED BY
THE APPROVED ORGANIZATION, PROVIDED THAT THE PLAN PAYS FOR PRESCRIPTION
DRUGS UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM UNDER SECTION THREE
HUNDRED SIXTY-FIVE-I OF THE SOCIAL SERVICES LAW. EVERY PRESCRIPTION DRUG
ELIGIBLE FOR REIMBURSEMENT UNDER THIS ARTICLE PRESCRIBED IN RELATION TO
A. 2335--B 6
A SERVICE PROVIDED BY THE APPROVED ORGANIZATION SHALL BE EITHER A
PREFERRED OR NON-PREFERRED DRUG UNDER THE QUALIFIED PRESCRIPTION DRUG
SYSTEM. IF THE APPROVED ORGANIZATION DOES NOT PAY FOR PRESCRIPTION DRUGS
UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM, THEN PAYMENT FOR
PRESCRIPTION DRUGS FOR THE APPROVED ORGANIZATION'S PATIENTS SHALL NOT BE
INCLUDED IN SUCH PAYMENTS AND PRESCRIPTION DRUGS SHALL BE PROVIDED FOR
THE APPROVED ORGANIZATION'S PARTICIPANTS UNDER THE PREFERRED DRUG
PROGRAM.
S 5. Subdivision 11 of section 270 of the public health law, as
amended by section 2-a of part C of chapter 58 of the laws of 2008, is
amended to read as follows:
11. "State public health plan" means the medical assistance program
established by title eleven of article five of the social services law
(referred to in this article as "Medicaid"), the elderly pharmaceutical
insurance coverage program established by title three of article two of
the elder law (referred to in this article as "EPIC"), [and] the family
health plus program established by section three hundred sixty-nine-ee
of the social services law [to the extent that section provides that the
program shall be subject to this article], AND THE CHILD HEALTH INSUR-
ANCE PROGRAM UNDER TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.
S 6. Section 272 of the public health law is amended by adding a new
subdivision 12 to read as follows:
12. NO PRIOR AUTHORIZATION SHALL BE REQUIRED UNDER THE PREFERRED DRUG
PROGRAM FOR:
(A) ATYPICAL ANTI-PSYCHOTICS; (B) ANTI-DEPRESSANTS; (C) ANTI-RETROVI-
RALS USED IN THE TREATMENT OF HIV/AIDS OR HEPATITIS C; (D) ANTI-REJEC-
TION DRUGS USED IN THE TREATMENT OF ORGAN AND TISSUE TRANSPLANTS; AND
(E) ANY OTHER THERAPEUTIC CLASS FOR THE TREATMENT OF MENTAL ILLNESS,
HIV/AIDS OR HEPATITIS C, RECOMMENDED BY THE BOARD AND APPROVED BY THE
COMMISSIONER UNDER THIS SECTION.
S 7. This act shall take effect on the one hundred eightieth day after
it shall become a law; provided, however, that section two of this act
shall take effect one year after this act shall become a law; and
provided further, that the amendments to section 369-ee of the social
services law made by section three of this act shall not affect the
repeal of such section and shall be deemed to expire therewith and
provided further, that the commissioner of health is immediately author-
ized and directed to take actions necessary to implement this act when
it takes effect.