BILL NUMBER: S9434
SPONSOR: RIVERA
 
TITLE OF BILL:
An act to amend part FFF of chapter 56 of the laws of 2020 relating to
directing the department of health to remove the pharmacy benefit from
the managed care benefit package and to provide the pharmacy benefit
under the fee for service program, in relation to pharmacy benefits
where a physician is authorized to dispense certain medications and
practices medicine in the oncology setting
 
PURPOSE:
This bill would modify the pharmacy carve-out for certain medications
for physicians practicing in oncology settings.
 
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 amends section 1 of part FFF of chapter 56 of the laws of
2020, relating to directing the Department of Health to remove the phar-
macy benefit from the managed care benefit package and to provide the
pharmacy benefit under the fee for service program, in order to add that
in relation to pharmacy benefits where a physician, or other licensed
health care providers, are authorized to dispense medications in accord-
ance with Section 6807 of the Education Law requiring that a provider
practicing medicine in an oncology setting and dispensing oncology drugs
or drugs related to an approved course of treatment used to manage symp-
toms related to cancer or cancer therapies would be exempted from the
transition to Fee-For-Service (FFS).
Section 2 provides the effective date.
 
JUSTIFICATION:
The 2020 New York State budget included provisions that transitioned the
Medicaid pharmacy benefit from Medicaid Managed Care (MMC) to Fee-For-
Service (FFS). This transition has complicated oncologists' ability to
dispense medications in office, and instead forces their patients to
travel to obtain prescriptions in pharmacies outside of where they are
being treated. The formula used to calculate physician-administered drug
rate under MMC is significantly higher than the rate used under the FFS
benefit, making it financially unsustainable for oncologists to store
and dispense these specialized medications in-office.
Cancer patients who are undergoing treatment require access to a variety
of medications which include pain and symptom management, maintenance,
pre-procedure, and preventative care medications. Adherence and access
to these medications presents a significant challenge for these patients
who undergo very complex treatment regimens, requiring coordination of
care and consistent and precise timing of medication consumption. The
ability to prescribe medications at on-site appointments creates a seam-
less process for providers and patients since cancer treatment typically
involves frequent adjustments to dosages or prescription changes which
necessitates continuous coordination between patients and their health-
care providers.
The inability to dispense in-office prescriptions creates a significant
risk for immuno-compromised patients who are required to travel off-site
to pick-up their medications. Pharmaceutical environments are frequented
by individuals with contagious illnesses which can be life threatening
to those with an already compromised immune system. In-office
prescriptions offer substantial benefits for cancer patients, including
eliminating additional transportation costs and risks; enhancing medical
adherence through direct provider oversight of medication changes;
reducing patient exposure to potentially infectious environments at
pharmacies; and reducing waste of unused medication.
This bill would authorize reimbursement for oncology physicians at the
MMC rate, rather than the lower FFS rate. This adjustment would enable
more oncology physicians to dispense in-office, thereby improving quali-
ty of care, treatment adherence, and overall health outcomes for cancer
patients.
 
LEGISLATIVE HISTORY:
New bill.
 
FISCAL IMPLICATIONS:
To be determined.
 
EFFECTIVE DATE:
This act shall take effect immediately