Last Updated on January 25, 2020 by Nirah Johnson

Expansion of Prescriber Prevails to cover Hep C medications would ensure Medicaid patients can obtain the antiviral drugs recommended by their medical provider.
March 16, 2016

Call to Action

The Latino Commission on AIDS has released a letter in response to NY Senate Senate seeking to repeal important patient protections in accessing medications in the state’s Medicaid program.

The letter asks that Majority Leader Flanagan, Speaker Heastie, and Coalition Leader Klein  oppose provisions that repeal prescriber prevails in Medicaid fee for service and managed care, and to consider expanding this important patient protection to all drug classes across both programs.

Read the letter below.  You can also read and sign the letter here

Dear Majority Leader Flanagan, Speaker Heastie, and Coalition Leader Klein,

The Senate and Assembly have played a crucial role in defending the rights and health of millions of patients across the state, including supporting patient access to medications in the state’s Medicaid program. Unfortunately, the Executive Budget is seeking to repeal important patient protections. On behalf of the undersigned and the patients we serve, we ask that you oppose provisions that repeal prescriber prevails in Medicaid fee for service and managed care, and that you consider expanding this important patient protection to all drug classes across both programs.

Patients and their health care providers face challenges when it comes to finding proper treatment, because no illness comes in a one-size-fits-all form. Responses to medications vary based on an individual’s age, ethnicity, and comorbidities, making it crucial that health care providers have the ability to select medications best suited to treat their patients’ unique needs. Prescriber prevails is a cost-effective means to help ensure that patients get the most appropriate treatments – and get treatments that they can adhere to. Appropriateness and adherence are proven to help avoid costly inpatient and emergency room care, as well as to improve quality of life.

In 2015, the Assembly and Senate passed legislation to require that a prescriber’s determination is final in managed care. Unfortunately, the Governor vetoed this measure. We request your consideration in inserting the bill’s provisions into the final budget. This measure would simply require that the prescriber prevails statute works as originally intended.

The Executive Budget also proposes to bypass the longstanding processes of the Medicaid Drug Utilization Review Board (DURB) by allowing prior authorization of drugs before they have been reviewed. The DURB is an independent body comprised of doctors, pharmacists, disease experts, and consumers who provide expert counsel to the Department of Health (DOH) regarding the Preferred Drug Program. According to the DOH website, the DURB is charged with helping to ensure if drugs are appropriate, medically necessary, and safe. It makes no sense to grant the DOH authority to bypass this important consumer protection body. We urge you to reject this proposal.

Regardless of disease state, all patients deserve equal and meaningful protections. We thank you for your time and attention to this issue.

History of Prescriber Prevails Advocacy and Legislation

Background

August 25, 2015

“Prescriber Prevails” refers to a provision in New York State Medicaid law that gives doctors the final say in disputes with Medicaid over which medications are prescribed to patients under the Managed Care Preferred Drug Program (PDP).

The law covers only certain classes of medications including:
  • anti-depressants
  • anti-psychotics
  • anti-rejections
  • seizure and epilepsy
  • endocrine, hematologic and immunologic

The law also includes anti-retroviral medicines, such as those used against HIV, but not antiviral drugs for hepatitis C.

The law has been a source of ongoing controversy and the number of medications covered by PDP has been cut and expanded several times. Lawmakers and public officials seek to require the use of lowest-cost drugs to reduce government spending, while patients and medical professionals seek to ensure cost concerns do not dictate quality of care decisions.

Requiring a patient to be treated with a medication solely based on cost, and over-riding a medical provider’s recommendation, can jeopardize patient short and long-term health, cause undue stress and even increase costs to the health care system for additional care that may be required due to ineffective treatment and/or complications.

Read on about the bill, Governor Cuomo’s veto, and how you can support this legislation.

 

Prescriber Prevails Expansion Bill Vetoed by Governor Cuomo on August 14, 2015

BILL NO A01174, sponsored by Assemblyman Robert Rodriguez, would have expanded Prescriber Prevails to all drug categories under Medicaid managed care plans (as well as Family Health Plus, and Child Health Plus), along with other protections designed to ensure patients are not blocked from optimal treatment under the PDP. In other words, under the law, if a prescriber “insisted” on prescribing a “non-preferred” drug,  the prescription would be approved.

The Bill Summary suggests that shifting prescribing to preferred drugs, while also protecting prescriber judgments on behalf of their patients, represents “a model of how to effectively organize health care.”

Unfortunately, the legislation will not be signed into law this year. The rationale behind Governor Cuomo’s veto can be read at the website of New York Health Works, which serves a resource and participation engine for New Yorkers interested in state health policy issues.

Legislation Critical to Increasing Patient Access to Most Effective Hepatitis C Treatments

Passage of Prescriber Prevails legislation is especially important for people with hepatitis C. It will ensure antiviral treatments for hepatitis C are protected, so thousands of NYS residents blocked by “penny-wise” policies have a chance to a cure. Many New Yorkers have been waiting years, even decades, to rid themselves of the hepatitis C virus. Like HIV, hepatitis C is life-threatening and infectious. The “silent” disease attacks the liver and causes cirrhosis, liver failure and liver cancer and can lead to premature death.

While new advanced treatments are rapidly being approved in the U.S., there is a major difference in cure rates based on individual patient characteristics. A number of medications may be used in different combinations and for different durations, based on clinical trials. Requiring treatment be determined by a doctor based on available evidence ensures patients have the best chance for optimal health outcomes and reduces long term cost to the health care system.

Call to Action

Advocates will not give up the fight for the protections offered in the Prescriber Prevails bill.  Supporters of this legislation  can watch for updates and make their voices heard:

  • Go to the New York Health Works website to sign up for updates and means to get involved.

 

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