WNYT.com

Provider Prevails restored for Medicaid recipients

Posted at: 07/10/2013 5:56 PM
Updated at: 07/10/2013 6:23 PM
By: Benita Zahn



18 year old Teagan Ketchum is a dynamo. A Newschannel 13 Dunkin Donut player of the week, excels at softball, volleyball and hockey and is heading to Sacred Heart University in the Fall. One more thing, she suffers from epilepsy.

Diagnosed in first grade it took much trial and error until doctors found the right drug therapy to control her daily seizures.

"At that point it was getting better to where I was only having one a week or so."

But then, about 3 years ago her insurer switched her drug to a generic with no prior warning and Teagen's health took a hit.

" And all of a sudden I was having one after another in the same day."

More trial and error until her doctor found another generic drug to control her seizures, but still, not as well as the name brand drug her doctor first prescribed.

Provider Prevails is the term used when what the doctor prescribes is filled.

Private insurance, as Teagan's family learned, is exempt.

And to save money New York did away with provider prevails for Medicaid part D recipients in October 2011.

That got Robert Bain from the epilepsy foundation to join with other health advocacy groups to implore the state legislature to restore the provision in the state budget.

 "There are plenty of places in state government to save money. I would look elsewhere ... Profound bad effects on somebody's life."

Their effort paid off and on July first provider prevails was restored. But Bain and others worry they'll be fighting this battle year after year. For lawmakers who would tinker, Teagen who's

"Stop. Don't do this."