S.5374- Restriction Prior Authorization of Anti-Viral Medications

Re:       S.5374 (Harckham) – AN ACT to amend the public health law, in relation to prohibiting health insurers, health care plans and HMOs from requiring prior authorization for anti-retroviral medication used to treat and prevent HIV infection.

This legislation, S.5374, prohibits prior authorization for the determination of anti-retroviral medication use in the treatment and prevention of HIV infections.  Health plans currently cover medications, in accordance with the recommendations of the United States Preventive Services Task Force (USPSTF). In June of 2019, the USPSTF gave the use of pre-exposure prophylaxis (PrEP) antiretroviral therapy for the prevention of HIV infection a Grade A recommendation. Under the Affordable Care Act (ACA), USPSTF recommendations with an A or B grade must be covered at no cost, which underscores that plans are currently covering PrEP and other anti-retroviral medication therapies.

Prior authorization is an important tool to protect patients from unnecessary and potentially harmful care. For example, it is utilized to help ensure that medications are safe, effective, and provide value for specific populations or subpopulations who may be affected differently by a medication, and to make sure that a medication is not co-prescribed with another medication that could have dangerous interactions. Additionally, it ensures that the clinician providing the care has the appropriate training to deliver the care being requested. Further, prior authorization enables health plans to improve care coordination by making sure care management supports are in place as members navigate the system and help with follow-up care and other services that help the member succeed in recovery. Prohibiting the use of prior authorization would remove critical protections for patients and undercut efforts to ensure that the care they receive is safe, affordable and effective.

When developing prior authorization policies, health plans review information on the use of inappropriate treatments, practice variation for specific services, the extent to which providers deliver care consistent with evidence, safety concerns, and other relevant factors to determine what services or drugs should be subject to prior authorization. Health plans regularly review the medical services and prescription drugs that are subject to prior authorization and make changes based on new evidence, adherence to recognized standards of care, or, in the case of new and emerging therapies, limited available evidence or safety concerns. These reviews are conducted by Pharmacy and Therapeutics committees with relevant clinical expertise.

HPA is concerned that eliminating prior authorization for these drugs will inhibits plans’ ability to coordinate care and treatment plans for members.  Treatment for HIV infections goes far beyond just taking medication, and prior authorization is one of the tools plans use to help streamline and manage patient care.

For these reasons, we urge you to reject S.5374.