Senator Carlucci Announces the Restoration of Prescriber Prevails Protections


Carlucci-HS-028Senator David Carlucci (D-Rockland/Westchester), chairman of the Senate Mental Health and Developmental Disabilities Committee, announced that prescriber prevails protections have been restored for atypical antipsychotic drugs and drug classes within Medicaid fee for services in the final Health Budget. In addition, it has been restored for eight additional drug classes, including: anti-depressants, anti-retroviral, anti-rejection, seizure, epilepsy, endocrine, hematologic, and immunologic therapeutic. This is a major victory for people with mental illnesses and physicians throughout the State who have fought to reinstate this vital provision.

Prescriber prevails for atypical anti-psychotic medications requires that if a physician determines that a medicine is necessary for an individual, even after an insurance health plan denies coverage, the physician’s determination is final and the plan must cover that drug. This requirement is vital for people with mental illnesses because these illnesses are very complex and individualized. These drugs also help an individual live a more stable and productive life, and without access to clinically appropriate medication, individuals have higher rates of emergency room visits, hospitalization, and other health services. It also ensures that prescribers have the full spectrum of medications available at their disposal to effectively treat an individual.

“I am pleased that we were able to restore prescriber prevails protections in this year’s budget, and in doing so we have sent a clear message that we cannot substitute cost for care,” said Senator Carlucci. “In light of a renewed emphasis focused on improving ones mental health, we recognize that mental illnesses are truly unique to each individual. In the end, we were only as successful as the people who stood behind us all the way through. This was a collaborative effort that would not have been possible without the assistance of countless advocates who believe that decisions medical decisions should be made by those with an M.D. next to their name.”

The governor proposed eliminating these protections for atypical antipsychotics in his Executive Budget just a year after they were first created. Mental health advocates, doctors, and people with mental illnesses opposed the governor’s proposals, arguing that this would mean the most cost-effective medication would be prescribed instead of what is clinically recommended by a health professional. Had this been the case, many individuals would have to go through a lengthy try and fail process in order to show that the covered drug does not work. During this long process, critics suggested that many individuals may become unstable and may run the risk of hospitalization.

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