A10249-2011 Actions

• Sep 4, 2012: enacting clause stricken
• Jun 14, 2012: reported referred to ways and means
• May 31, 2012: reported referred to codes
• May 16, 2012: referred to health

A10249-2011 Text

 S T A T E   O F   N E W   Y O R K
 
 10249
 I N  ASSEMBLY
 May 16, 2012
 
 Introduced by M. of A. P. RIVERA, GOTTFRIED -- read once and referred to
 the Committee on Health
 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 and chapter 56
 of  the laws of 2012 enacting the health and mental hygiene budget for
 the 2012-2013 state fiscal plan, 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.
 (B) "CLINICAL DRUG REVIEW PROGRAM"  MEANS  THE  CLINICAL  DRUG  REVIEW
 PROGRAM CREATED BY 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.
 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD15455-01-2
 
       A. 10249                            2
 (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 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 ARTI
 CLE (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 PARTIC
 IPANTS DIRECTLY OR INDIRECTLY (INCLUDING BY  REFERRAL),  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) "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.
 (J) "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.
 (K) "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.  PAYMENT FOR
 PRESCRIPTION DRUGS SHALL BE INCLUDED  IN  THE  CAPITATION  PAYMENTS  FOR
 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. 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.  THE COMMISSIONER SHALL APPROVE A MANAGED CARE
 PROVIDER'S QUALIFIED PRESCRIPTION DRUG SYSTEM  IF  IT  CONFORMS  TO  THE
 PROVISIONS OF THIS SECTION.
 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
 
       A. 10249                            3
 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, REIMBURSEMENT
 MAY BE DENIED UNLESS PRIOR AUTHORIZATION IS OBTAINED,  UNLESS  NO  PRIOR
 AUTHORIZATION IS REQUIRED UNDER THIS SECTION.
 (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 PROGRAM TO CONFIRM THAT IN
 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.
 (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
 
       A. 10249                            4
 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.
 (I)  NO PRIOR AUTHORIZATION UNDER A QUALIFIED PRESCRIPTION DRUG SYSTEM
 SHALL BE REQUIRED WHEN A PRESCRIBER PRESCRIBES A PREFERRED DRUG.
 (J) 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;  (IV)
 ANTI-REJECTION  DRUGS  USED  IN THE TREATMENT OF ORGAN AND TISSUE TRANS
 PLANTS; AND (V) ANY OTHER THERAPEUTIC CLASS FOR THE TREATMENT OF  MENTAL
 ILLNESS OR HIV/AIDS, APPROVED BY THE COMMISSIONER.
 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
 
       A. 10249                            5
 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.
 8. A MANAGED CARE PROVIDER FOR WHICH PAYMENT FOR PRESCRIPTION DRUGS IS
 INCLUDED IN ITS CAPITATION PAYMENT SHALL PERMIT EACH PARTICIPANT TO FILL
 ANY MAIL ORDER COVERED PRESCRIPTION, AT HIS OR HER OPTION, AT  ANY  MAIL
 ORDER  PHARMACY  OR  NON-MAIL-ORDER  RETAIL PHARMACY IN THE MANAGED CARE
 PROVIDER NETWORK, IF THE NON-MAIL-ORDER RETAIL PHARMACY OFFERS TO ACCEPT
 A PRICE THAT IS COMPARABLE TO THAT OF THE  MAIL  ORDER  PHARMACY.  EVERY
 NON-MAIL-ORDER  RETAIL  PHARMACY  IN THE MANAGED CARE PROVIDER'S NETWORK
 WITH RESPECT TO ANY PRESCRIPTION DRUG SHALL  BE  DEEMED  TO  BE  IN  THE
 MANAGED  CARE  PROVIDER'S  NETWORK  FOR EVERY COVERED PRESCRIPTION DRUG;
 PROVIDED, HOWEVER, THAT THE MANAGED CARE PROVIDER MAY LIMIT ITS  NETWORK
 OF  PHARMACIES  FOR SPECIFIED DRUGS, APPROVED BY THE COMMISSIONER, BASED
 ON CLINICAL, PROFESSIONAL OR COST CRITERIA. SUCH LIMITATION SHALL NOT BE
 BASED SOLELY ON COST.
 

S 2.

Section 55 of part D of chapter 56 of the laws of  2012  enacting
 the health and mental hygiene budget for the 2012-2013 state fiscal plan
 is 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 21 to read as follows:

 21. 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  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.
 
       A. 10249                            6
 

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  THE  PUBLIC
 HEALTH LAW.
 

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; (D) ANTI-REJECTION DRUGS USED IN
 THE TREATMENT OF ORGAN AND TISSUE TRANSPLANTS; AND (E) ANY OTHER  THERA
 PEUTIC  CLASS  FOR  THE  TREATMENT OF MENTAL ILLNESS OR HIV/AIDS, RECOM
 MENDED BY THE COMMITTEE 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 the commissioner of
 health is immediately authorized and directed to take actions  necessary
 to implement this act when it takes effect.

*By contributing or voting you agree to the Terms of Participation and Privacy Policy and verify you are over 13.

Discuss!