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New York State Medicaid Ending HIV ART Carve-Out
  It is my understanding that NYS is ending the care-out for HIV ARTs, what does this mean? My understanding is that now private payers will be handling coverage & they will have at their own option the decision as to whether or not to recommend generic ARTs, require pre-authorization or other harsh rules. The community should be looking into this & banding together as a coalition to be vocal in Albany. I understand of disease groups have been doing this but HIV appears absent.
Below is a brief outline of the enacted SFY 2011-12 Executive Budget impacting the pharmaceutical sector with corresponding Article VII bill language from A. 4009-D/S.
2809-D :
EPIC Restructuring. The enacted Budget modifies the Governor's proposal relating to the EPIC program. Part D premium assistance is restored while the proposal to significantly reduce EPIC assistance to coverage when an enrollee reaches the Part D "doughnut hole" is accepted. The EPIC panel is eliminated and its powers are transferred to the Commissioner of Health. [Part A, 1-3-n, pages 5-13]
Move pharmacy benefit into Medicaid Managed Care. The enacted Budget accepts the proposal to move the Medicaid pharmacy benefit from fee-for-service into Medicaid Managed Care. The change also moves the prescription drug benefit back into Family Health Plus. [Part H, 5-5-a, page 114]
Eliminate carve-out for currently exempt drug classes. The enacted Budget accepts the Governor's proposal to eliminate the "carve-out" of four classes of drugs from the Medicaid fee for service drug benefit - anti-depressants, anti-retrovirals, atypical antipsychotics and anti-rejection drugs - meaning these products may now be subject to prior approval for those beneficiaries who remain in fee-for-service Medicaid. [Part H, 21, page 120]
Prescriber Prevails. The enacted Budget has rejected the Governor's proposal to eliminate Prescriber prevails in the remaining fee for service benefit, thereby ensuring individuals in fee for service continue to enjoy this important protection. While there is some confusing language in the Aid to Localities appropriations bill, the statutory provisions providing for "prescriber prevails" remains intact and unchanged by the final Budget. [Part H, 18, page 119]
P&T Committee Changes. The enacted Budget implements a variety of changes to the Operation of the Pharmacy and Therapeutics Committee. The size of the committee will be increased from 17 to 18 and will be chaired by a member of the Department of Health staff. However, a provision allowing the Commissioner to designate DOH staff to make final decisions regarding the recommendations of the P&T Committee was rejected. [Part H, 13-16, page 119]
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